To the Applicant:
Provisions of the Family Education Rights and Privacy Act of 1974 give you the right to retain or
waive access to this recommendation. If you enroll at the University of Northern Iowa, you will be
accorded access to its contents unless you voluntarily waive your right of access. Indicate below for
your respondent whether or not you waive or retain your right of access to this recommendation.
I do
❑
waive my right of access
I do not
❑
waive my right of access
Applicant's signature_________________________________ Date________________
Please print your name and address__________________________________________
__________________________________________
__________________________________________
To The Person Writing the Reference:
Under the 1974 Family Education and Privacy Act, the applicant named above will have access to this
recommendation unless he or she has waived that right.
The person whose name appears above is applying for admission to the Master's of Social Work
Program at the University of Northern Iowa. You have been selected by the applicant as someone who
can be helpful to us in evaluating the applicant's readiness for a graduate program.
The Master of Social Work degree requires intensive study as well as sound judgment and emotional
stability. The successful applicant should have a concern for social issues, a commitment to working
with diverse populations, and the ability to think clearly and communicate well both verbally and in
writing. A person who enters a graduate program without a good degree of readiness in these areas
risks failure, and may have a difficult experience. Therefore, you are encouraged to be candid in your
assessment. Please answer the questions on the form as fully as possible. Please place the completed
reference in the envelope provided, seal, and sign over the flap (across the seal). Please return
the sealed envelope to the applicant. Your prompt response is greatly appreciated.
1) How long and in what capacity have you known the applicant?
2)
Please give your impression of the applicant's rating in the following areas:
Self Awareness (Insight into one’s own behaviors and impact of self on others.)
1
2
Low
3
Average
4
5
High
Unobserved or
Don’t Know
3
Average
4
5
High
Unobserved or
Don’t Know
3
Average
4
5
High
Unobserved or
Don’t Know
4
5
High
Unobserved or
Don’t Know
Empathy (Sensitivity to feelings, thoughts, perspectives of others.)
1
2
Low
Genuineness (Open, honest, transparent.)
1
2
Low
Warmth (Conveys positive regard, acceptance of others.)
1
2
Low
3
Average
Emotional Stability (Consistent, appropriate mood.)
1
2
3
Average
4
5
High
Unobserved or
Don’t Know
2
3
Average
4
5
High
Unobserved or
Don’t Know
3
Average
4
5
High
Unobserved or
Don’t Know
2
3
Average
4
5
High
Unobserved or
Don’t Know
2
3
Average
4
5
High
Unobserved or
Don’t Know
2
3
Average
4
5
High
Unobserved or
Don’t Know
2
3
Average
4
5
High
Unobserved or
Don’t Know
2
3
Average
4
5
High
Unobserved or
Don’t Know
Low
Ability to manage stress
1
Low
Ability to work with historically oppressed & other diverse populations
1
2
Low
Interest in Others (non -self-centered)
1
Low
Intelligence
1
Low
Ability to express thoughts & feelings –verbally
1
Low
Writing Ability
1
Low
Potential for Leadership
1
Low
TOTAL (1-60) =
3) Please discuss your personal knowledge of the applicant’s experiences as they may relate to
working with people. Please specify whether your knowledge comes from an employment, an
educational or community setting.
4) Please discuss the applicant's readiness for graduate study, including emotional maturity, strengths
and/or problem areas.
Recommendation:
I would:
❑ strongly recommend
❑ recommend
❑ recommend with reservations
❑ not recommend
Signature ______________________________________
Date___________________
Name (printed or typed) _________________________________________________________
Title____________________________________ Organization _______________________________
Address__________________________________________________________________________
Phone ___________________________________________________________________________