To the Applicant:
Provisions of the Family Education Rights and Privacy Act of 1974 give you the right to retain or waive access to this recommendation. If you enroll at the University of Northern Iowa, you will be accorded access to its contents unless you voluntarily waive your right of access. Indicate below for your respondent whether or not you waive or retain your right of access to this recommendation.
I do ❑ waive my right of access
I do not ❑ waive my right of access
Applicant's signature______Date______
Please print your name and address______
______
______
To The Person Writing the Reference:
Under the 1974 Family Education and Privacy Act, the applicant named above will have access to this recommendation unless he or she has waived that right.
The person whose name appears above is applying for admission to the Master's of Social Work Program at the University of Northern Iowa. You have been selected by the applicant as someone who can be helpful to us in evaluating the applicant's readiness for a graduate program.
The Master of Social Work degree requires intensive study as well as sound judgement and emotional stability. The successful applicant should have a concern for social issues, a commitment to working with diverse populations, and the ability to think clearly and communicate well both verbally and in writing. A person who enters a graduate program without a good degree of readiness in these areas risks failure, and may have a difficult experience. Therefore, you are encouraged to be candid in your assessment. Please answer the questions on the form as fully as possible. Please place the completed reference in the envelope provided, seal, and sign over the flap (across the seal). Please return the sealed envelope to the applicant. Your prompt response is greatly appreciated.
1) How long and in what capacity have you known the applicant?
2) Please give your impression of the applicant's rating in the following areas:
Self Awareness (Insight into one’s own behaviors and impact of self on others.)
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Empathy (Sensitivity to feelings, thoughts, perspectives of others.)
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Genuineness (Open, honest, transparent.)
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Warmth (Conveys positive regard , acceptance of others.)
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Emotional Stability (Consistent, appropriate mood.)
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Ability to manage stress
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Ability to work with historically oppressed & other diverse populations
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Interest in Others (non -self-centered)
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Intelligence
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Ability to express thoughts & feelings –verbally
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Writing Ability
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
Potential for Leadership
1 2 3 4 5 Unobserved or
Low Average High Don’t Know
TOTAL (1-60) =
3) Please discuss your personal knowledge of the applicant’s experiences as they may relate to working with people. Please specify whether your knowledge comes from an employment, an educational or community setting.
4) Please discuss the applicant's readiness for graduate study, including emotional maturity, strengths and/or problem areas.
Recommendation:
I would: ❑ strongly recommend
❑ recommend
❑ recommend with reservations
❑ not recommend
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