Fillable PUBLIC HEALTH SERVICE COMMISSIONED CORPS REFERENCE REQUEST (Indian Health Service)

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PUBLIC HEALTH SERVICE COMMISSIONED CORPS REFERENCE REQUEST (Indian Health Service)

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PHS-1813
Rev. 12/16
FORM APPROVED:
OMB No. 0937-0025
Exp. Date: 12/31/2019
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
Division of Commissioned Corps Personnel and Readiness
Recruitment Branch
1101 Wootton Parkway, Suite 100
Rockville, MD 20852
REFERENCE REQUEST FOR APPLICANTS TO THE
PUBLIC HEALTH SERVICE COMMISSIONED CORPS
To be completed by the applicant:
Applicant’s Name (Last, First, Middle Initial)
If the reference knows you -- the Public Health Service Commissioned Corps
applicant -- by any other name, e.g., maiden name, please indicate that name
here:
Only other names the applicant has used.
Your name has been given as a reference by the individual identified above who has applied for appointment to the Public Health
Service Commissioned Corps.
We would appreciate your frank and objective consideration of the requested information. To help us determine whether this person
is loyal, trustworthy, and of good character, we ask that you answer all questions on the front and back of this form as fully and
specifically as you can. The information you provide will be disclosed to the person identified above if he or she should so request.
The promptness of your reply will aid us greatly in our evaluation of this applicant. The information furnished by former supervisors,
employers, or college deans with the same or related background provides valuable information for use in evaluating applicants.
1. PERIOD OF ASSOCIATION
From
(MM/YYYY)
To
2. PROFESSIONAL RELATIONSHIP TO APPLICANT (CHECK APPROPRIATE BOXES.)
EMPLOYER
SUPERVISOR
TEACHER
DEAN
FACULTY ADVISOR
OTHER
(SPECIFY)
3. EVALUATION OF APPLICANT (PROVIDE ANY DETAILS IN SECTION 7.)
ELEMENTS OUTSTANDING
BETTER THAN
AVERAGE
AVERAGE BELOW AVERAGE
NO BASIS
FOR JUDGMENT
PRODUCTIVITY
ABILITY TO WORK INDEPENDENTLY
INITIATIVE
APPLICATION OF SKILLS AND KNOWLEDGE
CAPACITY FOR DEVELOPMENT
ATTENDANCE
DEPENDABILITY IN CARRYING OUT ASSIGNMENTS
ABILITY TO WORK WITH AND FOR OTHERS
FLEXIBILITY -- ADAPTABILITY
ABILITY TO SOLVE PROBLEMS -- RESOURCEFULNESS
ORIGINALITY
JUDGMENT
ABILITY TO COMMUNICATE (ORAL/WRITTEN)
SUPERVISORY ABILITY
(Continue on reverse side)
PSC Publishing Service (301) 443-6740 EF
Applicant’s Name:
(Last, First, Middle Initial)
4. APPLICANT IS BEST SUITED FOR WHAT SPECIALIZATION, FIELD, OR POSITION
5. DO YOU KNOW OF ANY LIMITATIONS OR OTHER INFORMATION WHICH MIGHT IMPACT ON THE EFFECTIVENESS OR STABILITY OF THIS PERSON?
(Training, Personality, Emotional, Ethical)
NO YES
(Give Details in this Space)
6. WOULD YOU BE WILLING TO EMPLOY OR RE-EMPLOY THIS PERSON IF YOU HAD AN OPENING REQUIRING THE GENERAL PROFESSIONAL LEVEL AND
PROFESSION OF THIS INDIVIDUAL?
YES
(IN WHAT CAPACITY?)
NO
(GIVE REASONS)
7. COMMENTS (Please use this space to supply any further information, comments from section 3 and/or evaluation.)
8. SIGNATURE
9. NAME
(Type or Print)
10. TITLE OR POSITION 11. DATE
12. INSTITUTION OR FIRM ADDRESS (Include ZIP Code) (Do not attach business
cards)
Telephone No.
( )
Ext.
PHS-1813
Rev. 12/16
(BACK)
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PUBLIC HEALTH SERVICE COMMISSIONED CORPS REFERENCE REQUEST (Indian Health Service)

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Completed 9 September 2020

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