SIU School of Medicine
CERTIFICATE OF HISTOTECHNOLOGY RECOMMENDATION FORM
Name of Applicant_______________________________________________________
Characteristic evaluated
Personal
Attendance
Punctuality
Communication
skills
Oral
Written
Listening
Motivation
Attitude
Initiative
Leadership
Ability
Academic Potential
Work with others
Adaptability
Problem solving
Interacts with clients
Work independently
Quality of Work
Organization
Accuracy
Technical competency
Excellent
Above
average
Average
Below
average
*Not
Apply
Maturity
Judgment
Emotional Stability
Responsibility
*This indicates you have not had the opportunity to observe this characteristic
Recommendation for Acceptance
[ ] Strongly recommend
[ ] Recommend with reservation
[ ] Recommend
[ ] Do not recommend
Please Type or Print
Your Name
Title
Organization/ Business/Institution
Contact Phone Number
Address, City, State, Zip Code
Signature
Date
I have known the applicant for ___________________years in the capacity of
SIU School of Medicine
CERTIFICATE OF HISTOTECHNOLOGY RECOMMENDATION FORM
Name of
Applicant_____________________________________________________
Permanent
Address_______________________________________________________
Dawg Tag
#_________________________Email______________________________
Please have this form completed by someone who is in a position to evaluate
your potential i.e. current or former instructor, advisor or supervisor. Some
individuals prefer confidentiality of their comments when completing
reference forms. Sign below if you wish to waive your right of subsequent
access to the reference document. Regardless of your decision on waiving
your right of future review, your application will be given full consideration.
Waive my right of subsequent access to this recommendation form
I do
[ ]
I do not [ ]
As required by the Family Educational Rights and Privacy Act, a student
may elect to waive subsequent access to this recommendation form. In either
case, the admissions committee would appreciate your opinion concerning
the named application above.
SIU SOM does not discriminate on the basis of race, creed, national origin,
sex, age, or disability in the recruitment and admission of students,
employment of faculty and staff as specified by federal laws and regulations.