Postgraduate Physician Assistant Critical Care Residency Program Application Form (Page 4 of 4) in pdf

APPLICANT EVALUATION FORM – PAGE 2

Maturity/Emotional Stability: ________________________________________________________________

_________________________________________________________________________________________

Personal Integrity: _________________________________________________________________________

_________________________________________________________________________________________

Professionalism: __________________________________________________________________________

_________________________________________________________________________________________

Flexibility/Ability to Adapt: __________________________________________________________________

_________________________________________________________________________________________

Have you observed the applicant’s interactions with patients?

Yes

If yes, please comment on the applicant’s interaction style: ______________________________________

_________________________________________________________________________________________

Additional comments:______________________________________________________________________

_________________________________________________________________________________________

May we contact you by telephone for additional information? ____________________________________

Recommendation concerning admission (check one):

The applicant has my highest recommendation.

I recommend the applicant with confidence.

I recommend the applicant with some reservations.

I do not recommend the applicant.

Signature ______________________________________________________________ Date _____________

Name Printed or Typed _______________________________ Title/Dept. _____________________________

Institution _________________________________________________________________________________

Address __________________________________________________________________________________

Telephone No (____) ________________________ E-Mail ________________________________________

Upon completion, please seal this form in the envelope provided by the applicant and place your

signature across the back seal. Return the sealed envelope directly to the applicant. The applicant

submits all application materials in one envelope.

Postgraduate Physician Assistant Critical Care Residency Program Application Form Page 4