Fillable Southern Utah University - BSN 2020 Admission Form

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Southern Utah University - BSN 2020 Admission Form

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  • 77 check-boxes
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SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
BACHELOR OF SCIENCE IN NURSING – BSN DEGREE PROGRAM – Fall 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard,
Cedar City, UT 84720, 435/586-1906, RobertsonV@suu.edu
TO THE APPLICANT: Please fill out section 1 ONLY for each evaluator. (Please Print)
SECTION 1
Name of Applicant: _________________________________________________________________________________
T Num
ber: _____________________________________________________________________
PLEASE N
OTE: “The Family Educational Rights and Privacy Act of 1974 and its amendments guarantee student access to
educational records concerning them. Students are also permitted to waive their rights to access to recommendations.
The fo
llowing signed statement indicates the applicant’s wish regarding this recommendation:
I waiv
e, _______ or I do not waive _______ my right to see this form or any supplementary notes or letters pertaining to this
reference form.
Applicant Signature
________________________________________________ Date____________________
TO THE EVALUATOR: Please complete sections 2, 3 and 4.
SECTION 2
You have been chosen by the applicant as a reference in support of an application for nursing study at Southern Utah
University. We are particularly interested in your appraisal of the applicant’s abilities and potential for further
education.
Evaluator’s Name_________________________________________ Title_______________________________
Your Pl
ace of Employment______________________________________ Phone _________________________
Comple
te
Address_______________________________________________________________________________________
Length of time you have known applicant____________________________________
Capac
ity in which you have known the
applicant_____________________________________________________________________________________
Signature___________________________________________________________ Date____________________
SECTION 3
OVERALL RECOMMENDATION:
I highly recommend this applicant for the Nursing Program.
I recommend this applicant for the Nursing Program.
I do not recommend this applicant for the Nursing Program.
Page 1 of 3
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SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
BACHELOR OF SCIENCE IN NURSING – BSN DEGREE PROGRAM – Fall 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard,
Cedar City, UT 84720, 435/586-1906, RobertsonV@suu.edu
SECTION 4
Evaluators should: (1) rate each statement independently, and (2) avoid a tendency to rate on general impressions. One
characteristic might influence the rating of all characteristics.
The following questions or statements identify a variety of traits, skills, attitudes, etc. Please indicate the degree to which
each quality is characteristic of the applicant you are rating by: (1) reading the statement carefully, (2) reading the points on
the scale, and (3) encircling the number of your choice on the scale.
Specific comments in each category are encouraged. If you do not feel that you have enough information to rate the
candidate on a particular item, please circle “UNABLE TO ASSESS”.
1. Problem Solving: Ability to identify and solve problems:
1 2 3 4 5
UNABLE TO ASSESS
Poor Average Excellent
2. Sense of Responsibility: Ability to complete tasks, duties & honors commitments:
1 2 3 4 5
UNABLE TO ASSESS
Doesn’t complete; Average Always completes;
Avoids responsibility Accepts responsibility
3. Maturity: Ability to conduct self in a mature, adult manner:
1 2 3 4 5
UNABLE TO ASSESS
Immature, childish Average Mature, adult behavior
4. Attitude: Based upon your experience, what type of attitude does the applicant project toward life, school, job, etc.
1 2 3 4 5
UNABLE TO ASSESS
Very negative Average Very positive
5. Caring Attitude: Does the applicant display a degree of caring for others?
1 2 3 4 5
UNABLE TO ASSESS
Very little Average Exceptional
6. Stress/Anxiety Response: Ability to deal with stressful, anxiety-producing situations:
1 2 3 4 5
UNABLE TO ASSESS
Poorly, ineffective Average Excellent
7. Motivation: Extent to which individual applies self:
1 2 3 4 5
UNABLE TO ASSESS
Uninspired Average Self-starter;
Systematically a hard worker
8. Appearance: Extent to which standards of appearance are met:
1 2 3 4 5
UNABLE TO ASSESS
Untidy Average Well groomed
Page 2 of 3
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
BACHELOR OF SCIENCE IN NURSING – BSN DEGREE PROGRAM – Fall 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard,
Cedar City, UT 84720, 435/586-1906, RobertsonV@suu.edu
9. Acceptance of Personal Feedback: Extent to which applicant accepts constructive critique and considers others points of view:
1 2 3 4 5
UNABLE TO ASSESS
Resents, rejects, Average Seeks, utilizes,
doesn’t respond responds effectively
10. Communication Skills: Ability to communicate with peers, co-workers, teachers, etc.:
1 2 3 4 5
UNABLE TO ASSESS
Expresses self Average Excellent expression;
poorly Fluent
11. Integrity: Extent to which applicant displays an ethical code:
1 2 3 4 5
UNABLE TO ASSESS
Cheats, untruthful, Average Always honest, admits error,
blames others for mistakes truthful, trustworthy
12. Interpersonal Relationships: Ability to cooperate and get along with peers, co-workers, teachers, employers, etc.:
1 2 3 4 5
UNABLE TO ASSESS
Inappropriate behavior; Maintains satisfactory Outstanding ability to work
generally antagonizes relationship well with others
13. How would you characterize the following regarding this applicant? (Additional comments may be placed on a separate page if
desired)
A. Greatest Strengths:
B. Weakest points:
C. Other comments:
Thank you for your help in evaluating the applicant. A separate letter is not required but can be included.
Please seal this form in the envelope provided, sign your name across the seal and return it to the applicant
or mail directly to:
SUU Department of Nursing
Attn: Vikki Robertson
351 W. University Blvd
Cedar City, UT 84720
(Please indicate students name on outside of envelope)
All Letters of Recommendations must be received at above location on or before February 14, 2020.
Page 3 of 3
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Completed 30 May 2020

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