Leadership Reference
Deadline for submission is February 19, 2016
Name of Applicant:
is applying for a Nurse Residency Position. The Nurse Residency is a 12-month clinical education
opportunity designed to develop a professional nurse with a broad foundation in Pediatric Nursing,
and strengthen critical thinking and clinical judgment abilities. The Nurse Resident will be expected to
deliver competent and skilled care to patients and families with a team orientation and an emphasis
on good customer relations. An applicant who is a current Cook Children’s Employee must
provide a reference from their current supervisor who can attest to the applicant’s suitability
to continue in a professional role.
My acquaintance with applicant was as:
Manager/Director
Immediate Supervisor
Other (specify
How long have you known this applicant?
Applicant rating: Check the column of the rating that is most applicable.
Outstanding
4
Above
Average
3
Knowledge and Ability in
Current Position
Interpersonal Relationships
Compassion and Concern
for Others
Critical Thinking
Professional
Accountability/Leadership
Communication Skills
Integrity
Collaboration
Safety
Initiative
1
Average
2
Below
Average
1
Do Not
Know
0
What qualities or characteristics does the applicant have that would contribute to his/her
success as a Nurse Resident?
I would recommend this person for a nurse resident position.
If no, please state concerns.
Yes
Printed Name:
_______________________
Date:
__________________________ Title:
No
___________________________________ Daytime Phone Number:
_______
Please submit this form via
E-mail to nurse.residency@cookchildrens.org (Attaching the form to your Cook Children’s e-mail
constitutes your signature)
OR
Send via Inter-Office Mail to
Nancy Murphy
Senior Secretary
Education Department
Cook Children’s Medical Center
901 Seventh Ave.
Fort Worth, Texas 76104
2