Reference for Potential Student at UT Tyler

This individual is requesting that you serve as a reference for his/her application for admission to The University of Texas at Tyler's graduate nursing program. All completed forms will be treated confidentially.

Applicant's Information

Program applicant is applying for *

Applicant's First Name *

Applicant's Last Name *

Other Names Used

Applicant's Email Address *

Evaluator's Information

First Name *

Last Name *

Credentials

Job Title *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Please rate this applicant in each of the categories below: *

	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Organization	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Writing Skills	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Oral Communication	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Analytic Skills	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Initiative	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Independence	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Maturity	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Perseverance	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Sense of Humor	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Application of Evidence in Practice	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Overall Academic Ability	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Leadership	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Collaboration	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess
Clinical Expertise	Excellent	Above Average	Average	Below Average	Poor	Unable to Assess

In what capacity do you know the applicant *

Are you able to directly evaluate their clinical skills? *

How long have you known the applicant *

Please help by sharing any additional information about this applicant that might help us assess their potential for success in the Graduate Nursing program at UT Tyler. *

By typing your name in the text field you are electronically signing this reference. *