Master of Science in Nursing
Regents Online Degree Program
Recommendation

Thank you for completing this reference.  Please complete and return this form to the graduate divivsion of the applicant's home school.  

___________________________________________ (address to be inserted by applicant)

Applicant Section  (to be completed by the applicant)

I, ___________________, have asked ____________________ to provide this reference. 

    Applicant name (please print)                                     Reference Name

The Family Educational Rights and Privacy Act of 1974 and its amendments guarantee students’ access to education records concerning them.  Students are also permitted to waive the rights to access references.  The following statement indicates my intent regarding this reference:

I waive  ______  I do not waive  ______  my right to see this reference or any supplemental notes or letters pertaining to it.

_________________________________________                                _____________________

Applicant’s Signature                                                                                        Date

Reference Section  (to be completed by the reference)

How long have you known this applicant?  ___________________________________

What was your relationship to the applicant?  _________________________________

Please rate this applicant in the following areas:	Excellent	Good	Average	Poor
Personal/professional integrity
Ability to be successful in an MSN program
Clinical competence
Initiative
Clinical judgment
Ability to work with others
Leadership ability
Probability of completing an MSN program
Writing ability
Intellectual curiosity

Overall Recommendation:  

Strongly Recommend            □           Recommend          □             Do not recommend     □

___________________________ ___________________________ ____________________________

Name of Reference (Please print)    Signature                                              Date

____________________________________________         ___________________________________

Organization                                                                                        Title

If you wish to provide additional comments, please attach a separate sheet.