Person Serving As Reference Form for BSN

(For best results, please fill out this form using the Google Chrome Browser.)

This form is to be used by the person serving as a reference for an applicant to the Northwestern Nursing Program. The information provided below will serve as that reference. This reference form will become a part of the student’s permanent file. According to the policy of the Northwestern Oklahoma State University Nursing Program, applicants have access to their personal file upon written request to the Chair of the Division of Nursing unless they waive their right to access. Your cooperation in completing and promptly submitting this form will assist both the applicant and the Nursing Program. Thank you for taking your time to complete this Reference Form. Your contributions are appreciated.

Reference Information

Full Legal Name *

Position *

Address *

City *

State *

Zip Code *

Email Address *

Information regarding applicant being provided for this reference

Name of applicant for whom you are providing this reference? *

How long have you known the applicant and in what capacity? *

What do you consider strengths or weaknesses of the applicant? Give examples when possible: *

Do you place confidence in the applicant’s integrity? Please explain. *

In what activities has the applicant taken an active part? *

What experiences has the applicant had that might have influenced the applicant's interest in nursing? *

Does the applicant interact positively with people? Please provide experiences that the applicant may have had that support your answer. *

Rate the applicant on a scale of 5 (highest) to 1 (lowest) on the following attributes. Superior is 5; Poor is 1.

Dependability *

Work Performance *

Appearance *

Character Traits *

Stability/Honesty *

Initiative/Creativity *

General Impression *

Additional Comments: *

Today's Date *

Terms & Conditions

Check this box as your electronic signature