Graduate Programs Reference Form - Nurse Practitioner Stream to be completed by Referee Please indicate the applicant’s program of choice: Combined Master’s of Nursing and Nurse Practitioner (MNNP) Post-Master’s Nurse Practitioner (PMNP) Applicant’s Name: Professor Supervisor Advisor I have known the applicant in my capacity as I have known the applicant for years and months Criteria Excellent Very Good Above Average Average Below Average Unable to Judge upper 2% upper 5% upper 10% upper 20% upper 30% upper 50% lower 50% 1. Clinical competence 2. Clinical assessment skills 3. General professional conduct and attitude 4. Potential ability as a Nurse Practitioner 5. Industry and perseverance 6. Clinical judgement 7. Critical thinking ability (logical, systematic) 8. Intellectual ability 9. Clinical teaching ability 10. Verbal clinical communication 11. Written clinical documentation 12. Overall evaluation of expertise as a clinician PLEASE DO NOT COMPLETE THIS FORM BY HAND, ONLY TYPED REFERENCE FORMS WILL BE ACCEPTED. Employer Other: please explain Page 1 of 2 FoN_reference_form_MNNP 2019/01
Transcript
Graduate Programs Reference Form - Nurse Practitioner Stream
to be completed by Referee
Please indicate the applicant’s program of choice:
Combined Master’s of Nursing and Nurse Practitioner (MNNP)
Post-Master’s Nurse Practitioner (PMNP)
Applicant’s Name:
Professor Supervisor Advisor I have known the applicant in my capacity as
I have known the applicant for years and months
Criteria Excellent Very Good Above Average Average Below
Average Unable to Judge upper 2% upper 5% upper
10% upper 20%
upper 30%
upper 50% lower 50%
1. Clinical competence2. Clinical assessment
skills
3. General professionalconduct and attitude
4. Potential ability as aNurse Practitioner
5. Industry andperseverance
6. Clinical judgement7. Critical thinking
ability (logical,systematic)
8. Intellectual ability9. Clinical teaching
ability
10. Verbal clinicalcommunication
11. Written clinicaldocumentation
12. Overall evaluation ofexpertise as aclinician
PLEASE DO NOT COMPLETE THIS FORM BY HAND, ONLY TYPED REFERENCE FORMS WILL BE ACCEPTED.
Employer
Other: please explain
Page 1 of 2 FoN_reference_form_MNNP 2019/01
Page 2 of 2 FoN_reference_form_MNNP 2019/01
1. Academic ability: Background preparation and course work
2. Clinical experience and skills: Strengths and challenges
3. Teaching and language ability: Presentation of reports or seminars, speaking ability
4. Research potential: Originality of thought, ability to synthesize ideas, critical/analytical thinking, skill at research design familiarity
with research methods and ability to express ideas clearly
5. If English is not the applicant’s first language please comment on proficiency in English
6. Additional comments (if desired)
Please Note: You may be contacted by phone for further details concerning the applicant
Highly Recommended Recommended Not Recommended Unable to Judge
Name of Referee & Credentials (Please Print/Type) E-mail address (Institutional or Business)
Position and Department Institution
Address (Institutional or Business) Telephone ( )
Fax Number ( )
Signature of Referee Date
This information is collected under the Post Secondary Learning Act. It is required to evaluate the application for admission to a graduate program and for scholarship purposes. Questions about the collection and use of this information may be directed to the Faculty of Nursing, Graduate Program,
Given your knowledge of the applicant and, if you were in a position to hire the applicant as a new Nurse Practitioner, please indicate below your hiring preference: I would...
Definitely hire Hire after some consideration Hire after careful consideration
Be reluctant to hire Definitely not hire
Please assist the selection committee by providing, in the box below, your evaluation of the applicant’s merits and shortcomings in each of these areas.
