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, one current or previous clinical supervisor who can evaluate
your current clinical competency and skills, Type or print the top section yourself.
Name: ___________________________________________________________________________________
Seeking Admission for: MSN ________________ Post-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: _________________________________________________________________________
Please numerically indicate the value that most approximately rates this individual's performance
Communication
Specialty area
stability
Ability to work
independently
a group
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signature
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