Professional Reference Form - CHRISTUS Trinity Mother Frances Health System

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NOTE: Reference must be competed by someone who is not a relative of the applicant.

REQUEST FOR PROFESSIONAL REFERENCE

The above applicant is being considered for admission to the Senior Extern Program at Trinity Mother Frances Hospital and Clinics.

We are requesting your help to aid the Admissions Committee in assessing the individual's professional and clinical competencies as a student nurse in order to be granted admission. Your cooperation in completing this reference will help the commttee gain a better understanding of the applicant.
* 2. Do you feel that within the boundaries of a student nurse, this nurse has provided care that is safe and effective?
* 3. Do you feel this applicant has the potential to develop critical decision-making skills?
* 4. Do you feel this applicant has the potential to develop the leadership skills of a professional registered nurse?
* 5. Please rate this student regarding their academic performance in his/her graduating class:
* 6. Please rate this student regarding their level of leadership in his/her graduating class:
* 7. Please rate this student regarding their level of maturity in his/her class as a whole:
* 8. Please rate this student regarding their level of integrity in his/her class as a whole:
* 9. Please rate this student regarding their level of ability to relate to his/her peers:
* 10. Please rate this student regarding their level of ability to relate to those in authority:
* 11. Please rate this student regarding their level of ability to accept responsibility:
* 12. Please rate this student regarding their level of ability to accept constructive criticism:
* 13. Please rate this student regarding their level of ability to be self-directed:
* 15. Do you recommend this person for admission?