Fillable Reference Form Revised - Reference form-Revised MSN

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Reference Form Revised - Reference form-Revised MSN

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The Reference Form Revised - Reference form-Revised MSN form is 3 pages long and contains:

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  • 10 check-boxes
  • 83 other fields

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File type: PDF

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1
Southeastern Recommendation Form
Southeastern Louisiana University
College of Nursing and Health Sciences
Graduate Nursing Program
STATEMENT OF RECOMMENDATION
To the Applicant: This form should be completed by at least one current or previous program
faculty who can evaluate your potential for graduate study and one current or previous clinical
supervisor who can evaluate your current clinical competency. Type or print the top section yourself.
Please sign before giving to the person writing the reference.
Name: ______________________________________________________________________________
Seeking Admission for: MSN ________________ DNP ___________________
Should you be admitted to the University, you would have the right, as a student, to review your
permanent record including this recommendation form on file with the University. Some persons prefer
not to complete recommendation forms, however, unless they can be assured of the confidentiality of
their comments. In any event, your application for admission will be given full consideration based on all
the information accumulated in your application file, including this form, regardless of your decision on
waiving your right to future review.
I do waive my right to subsequent access to this recommendation form
I do not waive my right to subsequent access to this recommendation form.
Applicant Signature: _____________________________________ Date: ________________
Person providing the reference:
Name/Title:
______________________________________________________________________________
Institution//Organization:
_____________________________________________________________________________
Address: ____________________________________________ Telephone: _______________
Relationship to Student:
_________________________________________________________________________
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2
Southeastern Recommendation Form
Please numerically indicate the value that most approximately rates this individual's performance
4=Excellent 3=Above
Average
2=Average 1=Below
Average
Not able to
evaluate
Academic ability
Written
Communication
Verbal
Communication
Knowledge of
Specialty area
Motivation
Emotional
stability
Ability to work
independently
Ability to work
in a group
Leadership skills
Initiative
Professionalism
Responsiveness
to Feedback
Research
Potential
Ability to
Problem Solve
Please use the rest of this form to share your evaluation of the applicant’s suitability to pursue
graduate or doctoral level study. Attach an additional page if necessary.
1. How well do you know the applicant? How long and in what capacity?
3
Southeastern Recommendation Form
2. Give your opinion of the applicant’s ability to do graduate work?
3. Give your opinion of the applicant’s expertise in his/her field.
4. Please add any additional comments:
Doctor of Nursing Practice (DNP)
Program
Master’s
Program
I would strongly recommend for
I would recommend for
I would recommend with reservations
for
I would not recommend for
Referee’s Signature: __________________________________________________
Date_________________
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signature
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4
Southeastern Recommendation Form
This completed form must be enclosed in a sealed envelope with the recommender’s signature over the
seal of the envelope. The applicant must submit all application documents along with this form in a
single envelope as described in the application instructions to:
Southeastern Louisiana University
Graduate Coordinator
College of Nursing and Health Science
SLU 10448
Hammond, LA 70402
If you have questions concerning this form, please call 985-549-5045 or send a message to
gradnurseadmin@selu.edu.
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Reference Form Revised - Reference form-Revised MSN

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Completed 2 March 2020

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