Health Science
Reference Form Instructions
To the Writer of the Reference:
1. Under the provisions of the Family Educational Rights and Privacy Act of 1974, the
applicant has the option of waiving the right to access his/her evaluation. Please determine
which option the applicant has chosen. If the applicant has neglected to sign the form and
check an option, please return the evaluation form to him/her. Remember, the signature
gives you written permission to evaluate the applicant, “in accordance with your own
professional and ethical standards.”
2. On the evaluation form, please provide both ratings and a written statement regarding the
candidate’s general ability.
3. Please place the completed form in an envelope, (provided by the candidate), write your
signature across the sealed flap and return to candidate.
4. Thank you for helping determine the qualifications of applicants stating interest in our
Health Science Programs.
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Post Office Box 1420
Lumberton, North Carolina 28359
Phone: (910) 272-3700
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Health Science
Reference Form Waiver
Reference for: __________________________
Date: __________________________
Dear________________________________:
This letter is a request that you evaluate my qualifications and suitability for admission to a
Health Science Program at Robeson Community College according to my performance with
you as my teacher, supervisor, employer and/or other _____________________________
[Circle appropriate one(s)]. I hereby grant you permission to rate my personal and professional
traits below in accordance with your own professional and ethical standards. This letter will
become a part of my admissions file. Thank you for your assistance.
I do not waive my rights of access to this evaluation and ask that it be non-confidential.
I hereby waive my right of access to and ask that this evaluation be confidential.
Applicant’s Signature: ________________________
Student ID: ________________________
Post Office Box 1420
Lumberton, North Carolina 28359
Phone: (910) 272-3700
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ROBESONCOMMUNITYCOLLEGE
ReferenceLetter
_________________________________hasappliedforadmissionintoaHealthScienceProgramatRobeson
CommunityCollege.Wewouldlikeyourcandidopinionoftheapplicant’ssuitabilityforthisprogram.The
informationprovidedwillbegivencarefulconsiderationandwillbekeptinutmostconfidence.
1. Howmanyyearshaveyouknowntheapplicant?_____________________
2. Whathasbeenyourconnection/relationshipwiththeapplicant?_____________________________________________
3. Inyouropinion,howwellsuitedistheapplicantforthiscareer?______________________________________________
4. Wouldyoubewillingtoemploythispersoninthehealthfieldifyouwerein
apositiontodoso?____________________
5. Remarks:(Pleaseaddanyfurthercommentsthatyouconsiderpertinenttoourgivingfullconsiderationtothis
applicant’srequest.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(Use backside of sheet if needed)
TRAIT SUPERIOR GOOD AVERAGE FAIR POOR
NOT
OBSERVED
Intelligence
PowerofExpression
Oral
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Character
Initiative
Leadership
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EmotionalStability
AcademicPreparation
AbilitytoWorkwithOthers
PersonalAppearance
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PrintName Signature
_______________________________________________ ______________________________________________
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