ODU Summer Application Reference Form

ODU School of Medical Diagnostic & Translational Sciences
Medical Laboratory Science Program
MLS Summer Immersion Program

One reference form is required. This form must be completed by an academic source (cannot be provided by the applicant's relative).
Applicant Name Applicant Name First Last
Name/Title of Evaluator
Phone Phone - ### - ### ####
Email
Organization
Waiver Access
The applicant reserves the right to view the reference. I have chosen to have this evaluation remain:

The applicant reserves the right to view the reference. I have chosen to have this evaluation remain: Confidential (Candidate will not have access to confidential evaluations) Not Confidential
Evaluator: Use the scale below to evaluate this applicant. Please select only one.
Academic Achievements

Academic Achievements Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Initiative

Initiative Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Dependability

Dependability Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Ability to Express Self

Ability to Express Self Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Integrity

Integrity Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Self Confidence

Self Confidence Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Leadership Abilities

Leadership Abilities Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Cooperation & Attitude

Cooperation & Attitude Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Responsibility

Responsibility Unable to Evaluate Unsatisfactory Below Average Average Above Average Excellent
Comments
In what capacity do you know this applicant?
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Deadline

The office must receive this evaluation no later than April 15th.
Date Date / MM / DD YYYY

ODU Summer Application Reference Form

ODU Summer Application Reference Form

One reference form is required. This form must be completed by an academic source (cannot be provided by the applicant's relative).

Waiver Access

Evaluator: Use the scale below to evaluate this applicant. Please select only one.

Deadline