Reference Form

Nova Southeastern University

Master of Science in Anesthesia Program

Page 1 of 2

Applicant Instructions:

Three references are required to complete your application for the Master of Science in AnesthesiaProgram for Nova Southeastern University. Recommendations should come from individuals who know

you well and can comment on your suitability and preparation for a health care career and your academic

preparation (not from family, friends or personal healthcare providers).

Please complete the following information and furnish a copy of this form to your designated references.

Your references will return the completed form and reference letter to Nova Southeastern University, Enrollment and Student Services or your Admissions Counselor.

Applicant: ________________________________________________________________________

Name CASAA ID or NSU IDReferences written in confidence are often of greater value in assessing an applicant’s qualifications. Please

read the statement below and indicate your preference with regard to the confidentiality of this evaluation.

In accordance with the Family Education Rights and Privacy Acts of 1974 (Public Law 93-380), I

understand that I have the right of access to this reference but may choose to waive that right. Below, my

preference is noted:

___ I waive my right of access to this reference form and accompanying letter.

___ I do not waive my right of access to this reference form and accompanying letter.

Applicant’s signature: _______________________________________________ Date: _______________

Evaluator Instructions:

Professional references are a valued and an integral part of the admissions process. The Anesthesiologist Assistant programs seek individuals who have the potential for success in a rigorous educational program

and possess the personal attributes required to become a competent and compassionate health care

professional.

Please complete parts I and II of this reference for the above named applicant. Return this document and

accompanying letter directly to Enrollment and Student Services or the Admissions Counselor.

PART I: Evaluation Form

Please complete the evaluation form found on page two of this document.

PART II: Letter of Reference

Please submit a letter of reference on professional letterhead for the above named applicant.

Comment on their motivation and suitability for a role as a health care provider. Additionally,

consider the qualities in the reference ratings below as well as integrity, motivation, commitment

and cultural sensitivity.

Your candid evaluation of the applicant will be of significant value and is appreciated.

EVALUATION:

EVEVALUALUAATTOR INFORMAOR INFORMATIONTION

Evalulator Name:

Title:

Occupation:

Organization:

Email:

Daytime Phone:

How long haHow long havve ye you known the applicant?ou known the applicant?

How well do yHow well do you know the applicant?ou know the applicant?

In what capacity do yIn what capacity do you know theou know theapplicant?applicant?

REFERENCE RAREFERENCE RATINGSTINGS

ExExcellentcellent GoodGood AAvvererageage Below ABelow Avvererageage PPooroor N/AN/A

Analytical Skills

Assertiveness

Integrity

Intellectual Ability

Initiative/Motivation

OrOral Communicational Communication

Reaction to CriticismReaction to Criticism

Organizational Skills

Professional Demeanor

TTeam Skillseam Skills

Written CommunicationWritten Communication

OvOvererall Evaluationall Evaluation

RECOMMENDATION CONCERNING ADMISSION:

1 Generated: 07-10-2017 02:24:34

Not Recommended Recommended with Reservation Recommended Highly Recommended

Applicant Name: Applicant Email: Date:

RETURN FORM WITH RECOMMENDATION LETTER TO: Enrollment Processing Services (EPS) via fax to (954)262-3607 or the Admission Counselor

Not Well Somewhat Well Very Well

Nova Southeastern University Dr. Pallavi Patel College of Health Care Sciences

Master of Science in Anesthesia Program3301 College Avenue

Fort Lauderdale, FL 33314-7796healthsciences.nova.edu/anesthesia/fort_lauderdale

Evalutator Signature: