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Referral Form

Medical Laboratory Science Program Recommendation Form

Hidden referral form

Notice to Evaluator: Your name and contact information were supplied by an applicant to the UPMC Medical Laboratory Science Program. Unless you have been notified otherwise, upon providing your name for completion of this electronic reference form, the applicant signed to waive his/her rights to access, in any way, to this confidential evaluation (reference: The Family Education Rights and Privacy Act of 1974 (FERPA), as amended).
Check the appropriate statement:*
- I have not been otherwise notified and thereby understand that the applicant has waived his/her rights to access this evaluation, assuring the contents will be held in strict confidence.
- I have been notified of the applicant's desire NOT to waive his/her rights to access this evaluation; therefore, I understand confidentiality is not guaranteed and any comments may be viewed by the applicant.
Applicant's Name*
Recommender's Name*
Title*
College / Company*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
In what capacity have you known the applicant?*
Duration of direct contact with the applicant*
Dear Recommender:
This applicant is being considered for a preceptorship in medical laboratory science, a highly technical and precise profession requiring dedication to studies and the utmost personal integrity. The UPMC Chautauqua Medical Laboratory Science Program places great emphasis on the importance of the testimony of those qualified to offer candid and honest assessment concerning the qualifications of the applicant. Thank you for your time as you openly provide your assessment to the capability, values and over-all impression of this applicant.
Compare this applicant with his/her peers as you have experienced historically over the year(s) in your position.

	Top 2%	Top 10%	Top 25%	Top 50%	Bottom 50%	No basis for evaluation
Chritical Thinking Skills (utilizes facts & logic)
Problem Solving Ability: (utilizes imagination/innovation)
Cultivates long-term memory: (learns to understand, not memorize)
Oral communication skills
Written communication skills:
Works well independently
Collaborates well on teams
Attendance & punctuality
Responsibility & reliability
Work quality and accuracy
Completes tasks on time
Asks questions to drive own learning
Response to constructive criticism
Level of personal motivation
Leadership potential
Personal integrity and honesty
Emotional stability when under stress
Maturity (relationships, decision making)
Positive attitude
Overall potential in a high-level, fast-paced medical-focused preceptorship

PART #2: Optional Comments
Expand upon the ‘Part #1 Characteristics’ should your scores require clarification to provide additional insight into the applicant; this section is optional. The laboratory preceptorship year is both academically and personally challenging so suggested comments include (a) strengths and (b) weakness in areas such as (1) academic, (2) personal and/or (3) professional qualities demonstrated by the applicant which reflect his/her aptitude for successfully completing our preceptorship.
NOTE: The text box below will automatically scroll to accept a full length document. If you have a reference letter prepared in another program such as Microsoft Word, you can copy and paste the document into the box.
*
Summary of Recommendation: Please select the statement that most nearly expresses your overall recommendation:*
- Recommended enthusiastically / Will perform at a superior level
- Recommended with confidence / Will do well in clinical training program
- Recommended / Acceptable / Should be able to complete clinical training program
- Recommended with reservation / May have difficulty completing clinical training program
- Not recommended / Unacceptable
- Unable to judge
Dear Evaluator:
By entering your name and the security code below and submitting this completed form, you are attesting to its trustworthiness in the same manner as a manual signature would signify. Thank you
Electronic Signature*
Security Code*
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