California State University, Northern California Consortium Doctor of Nursing Practice
September 2017
REFERENCE RATING FORM
DNP Applicant to complete top portion
Applicant Name: __________________________________________________
Applicants are advised that upon their admission to the School of Nursing, the Family
Educational Rights and Privacy Act of 1974 accords them the right to review these
recommendations unless that right is waived. While applicants are not required to agree
to make such a waiver, they are further advised that some individuals may not be willing
to supply a letter of recommendation in its absence. I have requested that this rating form
be completed by _________________________________________________ (name of
person writing the letter of recommendation and completing the reference rating form) for
use in the admission process to the DNP program. In accordance with the Family
Educational Rights and Privacy Act of 1974 I hereby:
_____ waive access to this report which should be considered confidential
_____ do not waive access to this report
___________________________________________________________________
Applicant’s Name – Print Clearly
___________________________________________________________________
Applicant’s Signature Date
Recommender to complete bottom portion and page 3
Please complete the rating scale below and attach to your letter of recommendation.
Place a circle or an “x” over the appropriate number that represents the applicant’s
rating. The rating of a 1 is Low and the rating of a 7 is High.
Independence and Self-Direction: sets own goals, organizes and prioritizes work, and
initiates/sustains activity to achieve goal
1 2 3 4 5 6 7
Responsibility and Accountability: responsible, dependable and accountable for own
actions
1 2 3 4 5 6 7
click to sign
signature
click to edit
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