How would you rate the applicant for each of the following characteristics?* Please select the rating that best describes the applicant in the category. Select N/O for not observed, if you have not had an opportunity to evaluate the characteristic or have no basis for the assessment.
Options for evaluation: Excellent(5)
Good(4)
Average(3)
Below Average (2)
Poor(1)
N/O(0)
What is evaluated:
1. Commitment to Learning the ability to self-assess, self-correct and self direct; identify needs and sources of learning; continually seek new knowledge and understanding.
2. Interpersonal Skills the ability to interact effectively with patients, families, colleagues, other healthcare professionals and the community; deal effectively with cultural or ethnic diversity issues.
3. Communication Skills the ability to communicate effectively (speaking, body language, reading writing, listening) for varied audiences and purposes.
4. Effective Use of Time the ability to obtain the maximum benefit from a minimum investment of time and resources.
Use of Constructive Feedback the ability to identify sources of and seek out feedback; to effectively use and provide feedback for improving personal interaction.
5. Ethical and Professional Behavior the ability to exhibit appropriate ethical and professional conduct and to represent the profession effectively.
6. Responsibility the ability to fulfill commitments, be accountable for actions and outcomes, and to persevere to achieve goals.
7. Critical Thinking the ability to question logically; identify, generate and evaluate elements of logical argument; recognize and differentiate facts, illusions, assumptions; distinguish the relevant from the irrelevant.
8. Stress Management the ability to identify sources of stress, develop effective coping behaviors, and adapt well to change.
9. Problem Solving The ability to recognize and define problems, use imagination and creativity to solve problems, analyze data, develop and implement solutions, and evaluate outcomes.
10. Leadership the ability to take initiative and motivate or guide others; generates ideas and plans or shares a vision for the future.
Taking into consideration these characteristics, how do you think this person would perform as a health care provider?
 I highly recommend this applicant as a health care provider.
 I recommend this applicant as a health care provider.
 I recommend this applicant as a health care provider, but with some reservations.
 I am not able to recommend this applicant as a health care provider.
Comments On your institutional or business letterhead, please comment on any of the ratings or provide any additional information that will help the admissions office in the application review process. Attach letter to this reference form.
