Clinical Laboratory Science Program
Selection into Clinical Year
Reference Form
To the Applicant: Complete the upper portion of this form and send it to the person
who has agreed to provide evaluation.
Student name and address
----------------APPLICANT MUST NOT WRITE BELOW THIS LINE ---------------To the Evaluator: The student named above is applying for selection into the clinical
year of the Clinical Laboratory Sciences Program at The University of West Florida.
Your evaluation of the applicant will assist the Selection Committee in identifying
students who are qualified to complete the Clinical Laboratory Sciences Program.
Under Florida law, this reference form will become part of the student's application and
must be made available to the student, parent or guardian upon request. Your
assistance with this important process is greatly appreciated. Please complete your
evaluation by February 21 (alternately June 17 ) and submit it to vdubose@uwf.edu.
1. How long, how well and in what capacity have you known the applicant?
2. Please indicate, if applicable, the class rank of the applicant:
3. Are there any special reasons why you think the applicant would be a good Clinical
Laboratory Scientist? If so, explain.
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4. Please highlight one box in each row which most accurately describes your
evaluation of the applicant according to the attributes listed in the left column.
I. Industry:
Willingness to
work
II. Thoroughness:
Accuracy,
carefulness,
exactness
Lazy, little or no
effort
III. Manual
dexterity: Ability to
perform manual
techniques
Very awkward,
unable to
perform manual
techniques
satisfactorily
No initiative,
seldom
originates any
work, follows
others
IV. Initiative,
intellectual
curiosity,
originality,
willingness to
attempt new ideas
V. Reliability:
dependability,
honesty,
responsibility
VI. Cooperation:
ability to work with
others, adaptable,
tactful, agreeable
VII.
Communication
skills: Ability to
transmit
knowledge orally
and in writing
VIII. Emotional
Control: poise,
moodiness,
temperament,
timidity,
emotionalism
IX. Intellectual
capacity:
Intelligence,
natural ability to
succeed in
academic effort
X. Prospect as
Clinical Laboratory
student
XI.
Recommendation
Careless, work
always
incomplete
Often unreliable,
irresponsible
Disagreeable,
antagonistic,
unable to work
with others
Ineffective,
unable to
transmit
information
Very poor control
of emotion, little
self confidence
Very slow to
learn
Should not
attempt Clinical
LabSciences
Program
Not
recommended
Seldom
completes
required work
Work sometimes
completed,
usually
inaccurate and
carelessly done
Awkward, able to
perform manual
techniques
satisfactorily with
extra practice
Sometimes
shows initiative
and willingness to
attempt new
ideas
Ordinarily does
required work
Unable to
evaluate
Work generally
completed,
reasonably
accurate
Works regularly,
occasionally
does extra work
Careful work,
accurate,
completed on
time
Performs manual
techniques well,
occasional
problem
Performs manual
techniques
exceptionally
well
Unable to
evaluate
Often initiates
new ideas and
projects
Marked ability to
think, plan out,
carry out new
ideas/projects
Unable to
evaluate
Varies,
sometimes
unreliable,
irresponsible
Slow to respond,
unwilling to help,
but improve with
mentoring
Frequent difficulty
transmitting
information
Has to be
prompted,
reliable on most
occasions
Tends to be
agreeable and
willing to help
Very reliable and
responsible
Unable to
evaluate
Does well in
team work,
agreeable
Unable to
evaluate
Adequate,
usually able to
transmit
information
Effective, no
difficulty
transmitting
information
Unable to
evaluate
Moderately well
balanced,
occasionally
loses self control,
moderate self
confidence
Needs to make
extra effort to
keep up
Well balanced,
poised, good
control of
emotions, usually
confident
Unusual poise
and self
confidence
Unable to
evaluate
Average
intelligence
Above average
intelligence,
quick to grasp
subject
Unable to
evaluate
Will have some
difficulty
Should have
average success
Should do well,
above average
Unable to
evaluate
Recommended
with reservations
Recommended
Strongly
recommended
Unable to
evaluate
Unable to
evaluate
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5. Do you know of any circumstances which would make it inadvisable for the applicant
to enter the field of clinical laboratory science? If yes, please explain.
6. Additional comments:
Please provide the following information about yourself.
Name
Title
Institution
Address
Phone
email
_____________________________________
Signature
*
__________________________
Date
*Electronic signature is accepted when document is emailed as an attachment from an
official email address.
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