Medical Laboratory Science Program Recommendation Form

Referral 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).

  • 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.

  • 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