BSW Hybrid Program
Page 1 of 2
REV 12/30/19
Letter of Reference
To be completed by the applicant:
This recommendation will become part of your admissions file. It will be used only for admissions considerations and will
not be disclosed to any unauthorized individual without your consent. If you are enrolled in the B.S.W. Hybrid Program at
Portland State University, you will be accorded access to its contents unless you voluntarily waive your right of access.
Please check one of the boxes and sign the statement below:
I have read the information above and I hereby: Waive Do not waive my right of access to this document.
To be completed by the reference: (Reminder: Application deadline is March 1st)
Reference Name: ___________________________________________(Please print)
The above named is applying for admission to the Baccalaureate Social Work Hybrid Program at Portland State University. Your
assessment of the candidate will assist the Baccalaureate Social Work Admissions Committee in making admission decisions. Under
the 1974 Family Education Rights and Privacy Act, the applicant named above will have access to this recommendation unless he
or she has waived that right.
1. How long and in what context have you known the applicant?
2. Please rate the applicant relative to other students or employees whom you have known in the same field in recent years by
placing an “x” on the point that best represents where the candidate lies on the continuum with 5 being ‘exceptional’ and 1 being
‘poor’. We are particularly interested in references who can speak to the applicant's capacity and potential to work effectively with
underrepresented groups.
Exceptional Poor
BSW Hybrid Program
Page 2 of 2
REV 12/30/19
3. We believe that such personal qualities as intelligence, maturity, emotional stability, sensitivity, resourcefulness, initiative,
follow-through, sound judgment, and a respect for others’ diversity are important for successful professional practice. Please
assess the applicant’s academic and/or professional promise within this context by attaching a separate letter with this reference
4. Summary Evaluation (please check only one)
____________ I strongly recommend this applicant for admission and believe that he/she has the capability to perform at a
superior level.
____________ I recommend this applicant for admission and believe his/her performance will be comparable to that of most
upper division students.
____________ I think that the applicant’s qualifications are marginal, but if admitted, the applicant would greatly benefit from
study in this program.
____________ I do not recommend this applicant for admission to the Baccalaureate Social Work Hybrid Program.
Signature_____________________________________________________ Date_____________________________________
Name____________________________________________________ Degree_______________________________________
Position__________________________________________ Employer_____________________________________________
Business Address (Street & No.)
City_________________________________ State_____________________ Zip Code________________________________
May we call you for additional information? ____Yes ____No
Phone _____________________________________ Email address________________________________________________
Please return this form and your letter directly to the applicant in a sealed envelope.
Please sign the envelope on the back of the sealed flap.
Thank you for your cooperation.