Bellarmine College
Lansing School of Nursing
Reference Form
I.
To be completed by student/graduate:
1, _____________________________, am requesting __________________________, a faculty member
of Bellarmine College, Lansing School of Nursing, furnish a reference to the below named agency.
I ( ) waive I ( ) do not waive my right of access to this recommendation form.
Print Name:____________________ Signature: _______________________ SS#: __________________
Reference should be mailed to:
(Name) _____________________________ (Name of agency): _________________________________
Street address: _________________________________________________________________________
City:______________________________________ State: _______________ Zip ___________________
Phone: (_________)___________________________ Fax: (_________)__________________________
Position applying for: ___________________________________________________________________
II.
To be completed by faculty:
Criteria
Excellent
Good
Fair
Poor
Scholastic ability
Clinical skills/Nursing interventions
Ability to work with others
Leadership ability/Potential
Attendance/Dependability
Communication skills
Adaptability
Relationship with student: Advisor: ______
Instructor: Theory _____ Clinical _____ Course(s) __________________________ Semester(s)_______
Length of time I have known student: _______________________________________________________
Additional remarks: _____________________________________________________________________
______________________________________________________________________________________
Faculty signature: _________________________ Title: ____________________ Date: _______________
Bellarmine College, Lansing School of Nursing, 2001 Newburg Rd., Louisville, KY 40205-0671
502-452-8215 / 1-800-274-4723 / Fax: 502-452-8058 / www.bellarmine.edu
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