REFERENCE FORM - Regional West Medical Center

REFERENCE FORM
Instructions for Reference Form use
• Please make a copy of this form for each of your references
• Have the individuals that you have chosen for references complete one of the
reference forms and seal it in an envelope
• The reference person must sign the back of the envelope over the sealed edge of the
flap
• Then you or the reference person can mail it back to Regional West Medical Center
School of Radiologic Technology. Send the reference to:
Regional West Medical Center
School of Radiologic Technology
4021 Avenue B
Scottsbluff, NE 69361
Unless these instructions are followed, the reference will not be used during the application
process.
NAME OF APPLICANT
The above person has listed you as a reference on the application for admission to Regional
West Medical Center School of Radiologic Technology.
Personal recommendations are very important in the selection of students for this Program.
Therefore, we ask you to provide a thoughtful and sincere appraisal of this applicant. The
contents of this reference form will be kept confidential and will be destroyed at the end of
the admission process. If you do not feel you can adequately evaluate the above named
applicant, please return the form with a notation of your inability to complete this form.
In what capacity have you been associated with the applicant?
____ As one of my students.
____ As one of my subordinates at work.
____ As a peer in a work situation.
____ As a friend.
____ Other capacity (specify)
How long have you known the applicant?
Signature
Printed Name
Mailing Address
Position
Date
66
Reference Form (page 1 of 2)

Please indicate your opinion of this applicant with regard to each factor listed.
Ability to relate to others
Dependability
Cooperation
Professional curiosity
Accuracy of thought/action
Emotional control
Personal motivation
Work ethics
Critical thinking/problem solving
Professional dress/behavior
Attendance/punctuality
Respect for authority/colleagues
Follows through
Learns from mistakes
Interpersonal skills
Academic potential
Leadership
Motivation
Written communication skills
Oral communication skills
Mathematic and computer skills
Sense of responsibility
Ability to work with people
Organizational ability
Ability to adapt to new situations
Ability to work independently
Overall evaluation
Excellent
Above
Average
Average
Below
Average
Poor
Not Able to
Evaluate
Comments
67
Reference Form (page 2 of 2)