REFERENCE FORM
ALLIED HEALTH DIVISION
Section I (to be completed by applicant):
is applying to the _____________________
(Name of Applicant)
(Name of Program)
program at Seward County Community College. References are required as part of the
admission process to this program. Your appraisal of the applicant will be appreciated
and will contribute to this process.
I give permission for
to provide this
(Reference Person)
reference for me.
This form should be mailed or faxed by the person completing the
reference form and the original sent by mail.
I understand that I have waived my right to see the submitted reference.
___________________
Date
_________________________________
Applicant's Signature
Section II (to be completed by the applicant’s work supervisor, employer, or instructor):
Please rank the applicant with careful thought and consideration in the following areas. Place the NUMBER in the corresponding
blank that best describes the interactions and observations you have had with this individual in the classroom or work setting as they
compare to other employees or students in their field. Each category (i.e. intellectual ability, motivation, etc.) will have only one
number. All information remains confidential and is viewed only by the application committee.
If you do not know the applicant well enough to evaluate, check here and return to the applicant._______
Intellectual Ability
0 points
Does not complete
assigned work
1 point
Partially completes
assignments after the
deadline. Does not
meet the criteria.
2 points
Completes assigned
work after the
deadline, meeting
the criteria provided
with some
assistance.
3 points
Completes assigned
work on time,
meeting criteria
provided with
minimal assistance.
4 points
Completes assigned
high quality work on
time, meeting the
criteria provided,
with minimal
assistance.
5 points
Self starter, works
individually with
creative abstract
thought turning in
exceptional, complete
assignments meeting
criteria provided.
0 points
Exhibits little or no
motivation to work
1 point
Requires strong
motivational tactics to
complete assignments
2 points
Requires minimal
prompting to
complete work
3 points
Completes work on
time without
prompting
4 points
Completes work on
time, assists others
demonstrating a
strong work ethic
5 points
Completes work on
time, assists others,
demonstrates
exceptional leadership
qualities
3 points
Clear speech with
proper grammar that
is easily understood
although eye contact
is only maintained
occasionally. Usually
listens when being
spoken to.
4 points
Clear, professional,
clearly understood
speech with proper
grammar. Has good
eye contact and
positive body
language most of the
time. Listens when
being spoken to.
5 points
Clear, professional,
clearly understood
speech with proper
grammar, good eye
contact with positive
body language,
listens closely when
being spoken to.
Corresponding
points
Motivation to
Work
Corresponding
points
Verbal
Communication
(Utilizing English)
0 points
Unable to speak
clearly to be
understood,
consistently uses
improper grammar,
does not listen,
negative body
language.
1 point
Improper grammar
with speech that is
difficult to
understand. & must
repeat statements.
Applicant appears to
listen some of the
time. Rarely makes
eye contact.
2 points
Utilizes proper grammar.
Able to understand their
speech most of the time.
Applicant must repeat
statements in order to be
understood. Occasionally
has good eye contact &
listening skills.
Corresponding
points
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Written
Communication
(Utilizing English)
0 points
Unable to write a
sentence or
paragraph that
makes sense.
1 point
Unable to write an
understandable
sentence or
paragraph without
much assistance.
2 points
Frequent difficulty
with proper sentence
structure, spelling, &
grammar.
Occasionally difficult
to understand the
meaning of their
written work.
3 points
Occasional difficulty
with proper sentence
structure, spelling,
and grammar
although meaning is
understood.
4 points
Able to communicate
clearly, utilizing
proper sentence
structure, spelling &
grammar with
minimal errors.
5 points
Able to communicate
clearly, consistently
utilizing proper
sentence structure,
spelling, & grammar
0 points
Unreliable. Does not
recognize own limits
regarding skills &
knowledge. Does not
finish assigned work.
Can’t handle
constructive criticism
or stressful situations.
1 point
Often unreliable
demonstrating
inconsistency with
work ethic.
Completes assigned
work late. Often has
difficulty recognizing
own limits, handling
constructive
criticism, &/or
stressful situations.
2 points
Dependable most of
the time. Sometimes
inconsistent with
work ethic or has
difficulty taking
constructive
criticism. Occasional
difficulty recognizing
own limits, &/or
handling stressful
situations.
3 points
Reliable &
accountable with
strong work ethic
although has
occasional difficulty
taking constructive
criticism or
recognizing own
limits. Has difficulty
handling stressful
situations.
4 points
Recognizes own
limits. Demonstrates
a strong work ethic,
reliability, &
accountability
although occasionally
has difficulty
handling stressful
situations.
5 points
Recognizes own
limits. Consistently
demonstrates
strong work ethic,
reliability, &
accountability.
Handles constructive
criticism well.
Maturity noted in
stressful situations.
0 points
Cannot follow verbal
or written
instructions.
1 points
Has much difficulty
following verbal &/
or written instruction.
Instructions must be
repeated.
2 points
Has some difficulty
following verbal
&/or written
instruction. Requires
occasional repeat of
instructions.
3 points
Able to follow verbal
& written
instructions with a
moderate amount of
assistance.
4 points
Able to follow
explicit verbal or
written instructions
with minimal
assistance.
5 points
Able to follow
explicit verbal or
written instructions
without difficulty.
Corresponding
points
Emotional Maturity
Corresponding
points
Teachable
Corresponding
points
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Ability to work with
others
0 points
Does not work well
with others. Expects
others to do his/her
assignment. Requires
frequent prompting
to do work. Does not
help others.
1 point
Not a team player.
Inconsistent about
completing assigned
work on time. Does
not help others
2 points
Team player at times,
although occasionally
inconsistent in
helping others &
completing assigned
work on time.
3 points
Good team player,
assisting others most
of the time.
Completes assigned
work on time.
4 points
Leadership qualities
noted. Works well
with others.
Completes assigned
work & offering
assistance to others
most of the time.
5 points
Strong leadership
ability. Works well
with others.
Completes assigned
work on time &
consistently offers
assistance to others.
0 points
Absent or tardy one
time a month or
more. Does not call
in prior to absence.
1 point
Absent or tardy one
time a month or more
in the past 6 months.
Called in to notify
prior to absence from
class or shift.
2 points
4 or 5 absences or
tardies in the past 6
months. Called in to
notify prior to
absence from class or
shift.
3 points
2 or 3 absences or
tardies in the past 6
months. Called in to
notify prior to
absence from class or
shift.
4 points
Only 1 absence or
tardy in the past 6
months, called in to
notify of absence
before class or shift.
Very dependable
5 points
No absences or late
arrivals in the past 6
months. Very
dependable.
0 points
Requires close
supervision. Unable
to make safe nursing
judgments or
demonstrate LPN
skills. Lacking
critical thinking
skills.
1 point
Requires close
supervision.
Demonstrates safe
nursing judgments
and LPN skills some
of the time. Lacking
critical thinking
skills.
2 points
Moderate amount of
supervision required.
Demonstrates safe
nursing judgments
and LPN skill most of
the time. Appropriate
critical thinking &
decision skills noted
at times with
guidance.
3 points
Moderate amount of
supervision required
at times. Usually
demonstrates safe
nursing judgments &
LPN skills.
Appropriate critical
thinking & decisionmaking skills noted
most of the time.
4 points
Works well with
minimal supervision.
Often demonstrates
solid knowledge &
LPN skills. Safe
critical thinking and
decision- making
skills demonstrated
with appropriate
decisions most of the
time.
5 points
Works well with very
minimal supervision.
Demonstrates solid
knowledge & LPN
skills. Consistently
demonstrates critical
thinking with safe &
appropriate decision
making skills.
Corresponding
points
Attendance/tardies
Corresponding
points
ADN applicant
only:
Clinical decision
making skills/
Knowledge of the
field of nursing
Corresponding
points
0
0
PN Total Score______÷
8 = ______
0
0
ADN Total Score______÷
9 = ______
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To your knowledge does the applicant have a problem with drug or alcohol abuse? Yes _____ No _____
I have known the applicant for _________ years _________ months
My relationship to the applicant is: Employer _____ Supervisor _____ Instructor _____ Other ______ (Describe other)
______________________________________________________________________________________________________________
Additional comments:
Strengths:
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Areas of concern:
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Signature
Date
____________________________________________
Position
Institution
___________________________________________
Phone number
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