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Student Reference Form

To the Evaluator: An applicant has requested that you evaluate him/her as a candidate to the Mercy Integrated CLS Program. Please complete this online form and submit.

Applicant Name:
Evaluator Name:
Telephone: () -
Email Address:

Applicants may waive their right of access to written evaluations as provided for under the education pricacy act of 1974. The applicant must notify the Evaluator and the Medical Technology Program Director, if they do not waive their right of access.

By checking this box the applicant has expressed their desire to waive their right of access to the confidential evaluation by the person named above and he/she should be hereby notified that the confidentiality of the evaluation is preserved.

By checking this box the applicant has expressed their desire to not waive their right of access to the confidential evaluation provided by the person named above, thus the confidentiality of the evaluation is not guaranteed.

Acquaintance with the applicant:
Length of time
In what capacity?

What is the applicant's major strength?

What is the applicant's major weakness?

The following traits are to be evaluated primarily on personal qualities believed relevant to an individual's performance and development in Medical Technology. Indicate your appraisal of the applicant below.

The alternate words in italics may not correlate with the trait for this individual. If it does not, please explain below.

Excellent Above Average Average Below Average Unsatisfactory Unable to Evaluate
Interpersonal Relations Skills
cooperative, tactful, assertive leadership potential
Character
honest, trustworthy, dependable, responsible, reliable, respectable, ethical
Communication Skills
articulate, clear, vocal, grammatical, responsive, attentive
Industry
diligent, prompt, aggressive, reliable, persistent, good organizer, initiative
Knowledge of Profession
opportunities, challenges, responsibilities
Maturity
stability, self-awareness, responsive to criticism, self-disciplined
Motivation
need to succeed, initiative, commitment
Personality
patient, humorous, warm, cheerful, positive
Personal Appearance
neat, clean, appropriate
Psychomotor Skills
agile, coordination, dexterous
Explanation:
Comments:

By typing my signature below and submitting it to Mercy Integrated Labs by the internet, I acknowledge, understand and agree that my electronic signature is the equivalent of a manual signature and that Mercy Integrated Labs may rely on it as such.

Signature of Evaluator:
Date:
Title:
Institution:

If you would like to share any additional information, please call, send, fax or email:
Karlyn Lange, MT (ASCP)
Mercy Integrated CLS Program
2222 Cherry Street
Toledo, Ohio 43608
Phone: 419-251-8252
Fax: 419-251-7816
Karlyn_Lange@mhsnr.org