CONFIDENTIAL RECOMMENDATION FORM
University of Texas Southwestern Medical Center
Allied Health Sciences School


APPLICANT: Complete the following portion of this form.

Applicant Name ________________________________________________

Application Program_______________________________________________

The Family Educational Rights and Privacy Act of 1974 and its amendments guarantees students access to education records concerning them.  Students are permitted to waive their right of access to recommendations.  The following signed statement indicates the wish of the applicant regarding this recommendation.

Check one of the following:

_____ I hereby WAIVE my right to inspect the contents of the following recommendation.

_____ I do NOT waive my right to inspect the contents of the following recommendation.

Name of Recommender_________________________________________________

Title___________________________________

Institution/Employer____________________________________________________

Phone Number___________________________

AUTHOR OF RECOMMENDATION: Complete the following information and return it in a sealed envelope to UT Southwestern or the applicant.  Place your signature across the flap of the sealed envelope.  Please do NOT submit a separate letter of recommendation in addition to this form.

In what capacity have you known this applicant?  ____ Academic Advisor   ____ Volunteer Supervisor   ____Instructor   ____ Supervisor/Manager   ____Other__________________________

How long have you known this applicant?  __________________________________

How well do you know the applicant?  ____ Very well ____ Somewhat ____ Not well


Rate the applicant on the following characteristics using the following scale:
5 - Outstanding; 4 - More than satisfactory; 3 - Satisfactory; 2 - Needs improvement;
1 - Unsatisfactory; 0 - Not observed

Effective Communication
Verbal and/or written
5---------------4---------------3---------------2---------------1--------------0

Interpersonal Skills
Friendly, cheerful, appropriate
5---------------4---------------3---------------2---------------1---------------0

Cooperates well with others
5-----------------4-----------------3-----------------2-----------------1-----------------0

Professional Appearance
Neat, clean, well groomed
5-----------------4-----------------3-----------------2-----------------1-----------------0

Professional Characteristics
Dependable, honest, mature
5-----------------4-----------------3-----------------2-----------------1-----------------0

Eager to learn, motivated
5-----------------4-----------------3-----------------2-----------------1-----------------0

Leadership qualities, respected by others
5-----------------4-----------------3-----------------2-----------------1-----------------0

Professional Work Habits
Well-organized, self-disciplined
5-----------------4-----------------3-----------------2-----------------1-----------------0

Capacity for Independent Critical Thinking
Problem-solving skills
5-----------------4-----------------3-----------------2-----------------1-----------------0

Emotional Stability
Reaction to stress, poise, control, inspires confidence
5-----------------4-----------------3-----------------2-----------------1-----------------0


ADDITIONAL COMMENTS:

Please provide any additional comments that would be helpful in the assessment of the applicant's ability to successfully complete an academic program to prepare leaders for the healthcare industry.  (Optional)
































OVERALL ASSESSMENT OF THE APPLICANT:

_____ Highly Recommend

_____ Recommend without Reservation

_____ Recommend with Reservation

_____ Do Not Recommend


Sign below and return this form in a sealed envelope (put your signature across the flap of the sealed envelope) to UT Southwestern or the applicant.  This form must be returned to complete the application process.

Recommender's Name_____________________________________________________________

Recommender's Signature_________________________________________

Date_________________________


Admissions Office
The University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard
Dallas, Texas 75390-9162
214-648-5617 or admissions@utsouthwestern.edu

UT Southwestern Medical Center is an Equal Opportunity Institution