Reference Form

Graduate Teacher Licensure (GTL) Program

This section tobe filled out by the applicant.
 I hereby waive my right of access to this reference.
 I do not waive my right of access to this reference. (Please include a self addressed and stamped envelope with this form.)
Applicant’s name: ______Tech ID: ______
______
Signature Date
Intended Program (Check One):
 Teaching Certificate only (Post-Bac)  Masters degree with teaching certificate (MAT)
Where do you intend to attend the Tuesday evening education classes?
 MSU, Mankato Campus  MSU 7700 France Campus in Edina
This section to be filled out by the reference.
1. I have known the applicant:
less than one year
casually / one to two years
fairly well / more than two years
very well
2. The applicant was (Check all that apply):
 student in class /  volunteer /  employee /  colleague /  other (specify ______)
3. Based on your ratings of the applicant (see evaluation form), please indicate your
recommendation below:
I recommend the applicant without hesitation.
I recommend the applicant with some hesitation (please explain in comment section).
I do not recommend the applicant for admission to the graduate teacher licensure program in Educational Studies: K-12 and Secondary Programs (explain in the comments section).
4. In rating the applicant, please keep in mind the comparison group you indicate below:
 Undergraduate  Master’s student  Other (specify: ______)

NOTE:Applicants in all teacher licensure programs at MSU must document, at minimum, a satisfactory performance on all of the dispositions. Listed below are the dispositions associated with professionalism. A disposition is a state of mind that leads one to act in certain ways; dispositions are reflected through behaviors.

Minnesota State University, Mankato

Showing Professionalism

Student Name: ______

Criteria / Unsatisfactory / Meets Expectations / Exceeds Expectations / Not observed
Respectful relationships / SP1. Interacts with students, co-workers, parents, and community in a positive, professional manner
SP2. Perceives and respects the physical, emotional, and social boundaries of others
SP3. Perceives and respects diversity among groups of people and individuals based on age, ethnicity, race, socioeconomic status, gender, exceptionalities, language, religion, sexual orientation, and geographical area
SP4. Listens and values others’ ideas
Integrity / SP5. Adheres to the guidelines for ethical conduct as described by Minnesota Bd. Of Teaching
SP6. Maintains confidentiality standards
SP7. Values and demonstrates honesty
Responsibility and work ethic / SP8. Arrives on time and completes assigned tasks on schedule
SP9. Accepts personal responsibility for one’s own actions
SP10. Arrives ready and able to support students’ intellectual, academic, social, and emotional growth
Commitment to teaching and professionalism / SP11. Engages in professional growth: reading, scholarly work, conferences, workshops and further coursework
SP12. Uses proper grammar and vocabulary in written and oral communication
SP13 .Maintains personal hygiene
SP14. Dresses appropriately

Filled out by: ______Date: ______

Signature

______

Printed Name

Please provide additional comments on the next page.

A member of the Minnesota State College and Universities System. MSU is an Affirmative/Action/Equal Opportunity University. This document is available in alternative format to individuals with disabilities by calling the Office of Clinical & Field Experience at 507-389-1517(V), 800-627-3529 or 711(MRS/TTY).

Additional Comments:

6/2010