ULM Title IV-E BSW Child Welfare Training Project – STUDENT REFERENCE FORM

The student identified below is applying to participate in the ULM Title IV-E BSW Child Welfare Training Project. Please complete this form and return by ______as absence of a complete application will result in possible lessening of the student applicant’s chances in this competition. Please return in the self-addressed envelope to:

ULM Title IV- E Child Welfare Training Project

Attention: Project Director

ULM Social Work Department, 217 Stubbs Hall

700 University Avenue, Monroe, LA 71209-6236

Student Applicant Name

REFERENCE NAME

ADDRESS

PHONE (W) (H)

In what capacity do you know the applicant and his/her work related to child welfare?

1.  Please describe this student’s motivation to learn:

Extremely high High Moderate, but sufficient to succeed Insufficient

2.  Please describe this student’s perseverance with tasks and assignments:

Extremely high High Moderate, but sufficient to succeed Insufficient

3.  Would you say this student is self-motivated, responsible, and conscientious?

Extremely high High Moderate, but sufficient to succeed Insufficient

4.  Would you say that this student is empathetic and accepting of disadvantaged clients?

Extremely high High Moderate, but sufficient to succeed Insufficient

5.  Please rate this applicant’s verbal skills:

Extremely high High Moderate, but sufficient to succeed Insufficient

Please continue on reverse!

6.  Please describe this applicant’s writing skills:

Extremely high High Moderate, but sufficient to succeed Insufficient

7.  Please describe this applicant’s interpersonal skills:

Extremely High High Moderate, but sufficient to succeed Insufficient

8.  How would you evaluate this student’s interest and motivation to specifically

work with families and children?

Extremely high High Moderate, but sufficient to succeed Insufficient

9.  As best as you can determine from your experience, do you believe this student has the potential for the professionalism and ethics necessary to work with child protection, foster care, and adoptions?

Extremely high High Moderate, but sufficient to succeed Insufficient

10.  Add any additional comments you would like regarding this student’s application:

______

Reference Person’s Signature Date

Title