Graham Hospital School of Nursing

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Personal Reference Form

To Be Completed by the Person Giving the Reference

Name of Applicant

Nondiscriminatory Policy

Equal opportunities are provided for all who apply regardless of race, color, national origin, creed, sex, age, or marital status. Section 504 of the Rehabilitation Act of 1973 protects all handicapped persons against discriminatory treatment. The Graham Hospital School of Nursing does not discriminate in matters of sex, handicap, age, marital status, race, religion, or national origin in admission or access to, or treatment in its programs, or activities.

Your evaluation of the applicant’s personal qualifications is important in considering his/her interests and ability and will be handled confidentially. Please feel free to add an additional page for any other comments.

Place an X in the appropriate spaces below according to the following scale:

4 – Excellent 3 – Satisfactory 2 – Unsatisfactory 1 – No Basis for Judgment

In each instance, please comment on the factors you considered in arriving at your rating.

Comments
Adaptability
Adaptability Rating
Dependability
Dependability Rating
Emotional Stability
Emotional Stability Rating
Initiative
Initiative Rating
Integrity
Integrity Rating
Judgment
Judgment Rating
Leadership Ability
Leadership Ability Rating
Oral Expression
Oral Expression Rating
Relationship with Peers or Co-workers
Relationship with Peers or Co-workers Rating
Written Expression
Written Expression Rating
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