References

You have been requested by the above applicant to be a reference for his/her admission into CURE’s ultrasound training center. Your candid appraisal of this applicant is appreciated. Please fill out all requested information in this form and return this report at your earliest convenience to the applicant for submission with his/her application.

Applicant’s Name Applicant’s Contact Number Applicant’s Address (Street, City, State)
 
Name of Reference Reference Phone Number Reference Alternate Phone Number
 
Email Address of Reference
Date of Reference
What is your relationship to the applicant?
How long have you known the applicant? (Years/Months)

The field of Diagnostic Medical Sonography requires an individual to be motivated, compassionate, detail oriented and trustworthy with the ability to work in a team environment to promote the well being of the patient.

Do you consider the applicant capable of carrying out these responsibilities?
Yes No
 

Please indicate the percentage of time would you say the following characteristics are displayed by the applicant:

Motivation to learn and achieve
100% 90% 75% 50% <50%
Accepts and carries out responsibilities
100% 90% 75% 50% <50%
Punctual and present for work/school assignments
100% 90% 75% 50% <50%
Expresses ideas/thoughts clearly (oral and written)
100% 90% 75% 50% <50%
Positive attitude toward others
100% 90% 75% 50% <50%
Maturity in actions
100% 90% 75% 50% <50%
Emotional stability
100% 90% 75% 50% <50%
Integrity
100% 90% 75% 50% <50%
Attention to detail
100% 90% 75% 50% <50%

Please provide any comments you wish to support or illustrate the applicant’s traits or characteristics that may enhance or inhibit his/her future as a Diagnostic Medical Sonographer.
Please indicate your overall recommendation for the applicant’s admission into the program:
Recommend strongly Recommend with confidence Recommend with reservation Do not recommend
 
By submitting this form, I understand that I may be contacted at the email and/or telephone number(s) provided and will be able to verbally verify the information provided.