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Johns Hopkins Hospital (Johns Hopkins Medicine)

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  • 4 check-boxes
  • 53 other fields

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APPLICANT EVALUATION FORM
Johns Hopkins Hospital
Postgraduate Physician Assistant Critical Care Residency
Applicant: Please fill in your name, mailing address and sign APPLICANTS WAIVER OF RIGHT OF
Waiver. Provide a standard business size envelope to Evaluator ACCESS TO CONFIDENTIAL
or have them email this form directly to paccres@jhmi.edu
. STATEMENT: I hereby freely and
voluntarily waive my right of access to
to any information contained
On this recommendation form and
Evaluator: Please fill out this form or provide a letter of recommendation agree that the student shall
regarding the applicant. If writing a letter instead, be sure to include remain confidential.
comments on all of the categories listed on this evaluation form. The
evaluation form or letter can be mailed in the envelope provided by the
applicant or emailed by you directly to paccres@jhmi.edu. Because of ______________________
federal legislation giving students access to educational records, the PA (signature)
Critical Care Residency Program cannot guarantee the confidentiality of your ______________________
statement unless the applicant has signed the waiver printed at the right. (date)
Applicant’s Name :________________________________________________________________________
Last First Middle
Applicant’s Mailing Address: _______________________________________________________________________
Street City State Zip
Applicant's Email address:________________________________________________________________________
_________________________________________________________________________________________
To the person recommending the applicant: The Johns Hopkins Hospital Postgraduate PA Critical Care
Residency Program greatly appreciates your completion of this form. If you are returning this form directly to
the applicant, please seal your evaluation in the envelope provided by the applicant, and write your name
across the back seal. The form can also be emailed directly to paccres@jhmi.edu. Thank you!
For how long, and in what relationship, have you known the applicant? ____________________________
_________________________________________________________________________________________
Please comment on the strength and weaknesses of the candidate according to your knowledge of him/her, in
the following areas:
Intellectual Ability: _____________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Motivation/Perseverance:___________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Ability To Work With Others: ________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
APPLICANT EVALUATION FORM – PAGE 2
Maturity/Emotional Stability: ________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Personal Integrity:
_________________________________________________________________________________________
_________________________________________________________________________________________
Professionalism: __________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Flexibility/Ability to Adapt:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Have you observed the applicant’s interactions with patients? Yes No
If yes, please comment on the applicant’s interaction style: ______________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Additional comments:______________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
May we contact you by telephone for additional information? ____________________________________
Recommendation concerning admission (check one):
The applicant has my highest recommendation.
I recommend the applicant with confidence.
I recommend the applicant with some reservations.
I do not recommend the applicant.
Signature ______________________________________________________________ Date ______________
Name Printed or Typed _______________________________ Title/Dept.______________________________
Institution ________________________________________________________________________________
Address __________________________________________________________________________________
Telephone No (____) ________________________ E-Mail _________________________________________
Upon completion, please seal this form in the envelope provided by the applicant and place your
signature across the back seal and mail directly to residency program or give back to applicant. The
form can also be emailed by the evaluator directly to the residency email address provided on this form.
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Johns Hopkins Hospital (Johns Hopkins Medicine)

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Completed 14 September 2021

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