CONFIDENTIAL LETTER OF REFERENCE

APPLICANT NAME:	applicant
YOUR NAME:	Your name
DATE:	date

Based on your understanding of the Advanced Training in Healthcare Ethics on our website, please provide your ranking and assessment of the above named applicant. We understand that your time is valuable and appreciate your effort in providing this reference. Please send your completed form to us at hlthethx@uw.edu.

MARK YOUR RANKING BY PLACING AN “X” IN THE BOX FOR EACH CRITERION IN THE TABLE BELOW:

CRITERIA	TRULY EXCEPTIONAL	OUTSTANDING	ABOVE AVERAGE	AVERAGE	BELOW AVERAGE	N/A – UNABLE TO ASSESS
Intellectual potential	☐	☐	☐	☐	☐	☐
Creativity/imagination	☐	☐	☐	☐	☐	☐
Oral communication skills	☐	☐	☐	☐	☐	☐
Written Communication skills	☐	☐	☐	☐	☐	☐
Ability to work with others	☐	☐	☐	☐	☐	☐
Ability to work independently	☐	☐	☐	☐	☐	☐
Motivation	☐	☐	☐	☐	☐	☐
Maturity	☐	☐	☐	☐	☐	☐
Flexibility/open to other’s perspectives and opinions	☐	☐	☐	☐	☐	☐
Overall promise/potential to succeed	☐	☐	☐	☐	☐	☐

PROVIDE A CANDID ASSESSMENT OF THE APPLICANT’S POTENTIAL FOR SUCCESS IN THE ADVANCED TRAINING IN HEALTHCARE ETHICS PROGRAM. PLEASE DESCRIBE THE NATURE OF YOUR PROFESSIONAL RELATIONSHIP WITH THE APPLICANT (no word limit):

Detailed assessment

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

Signature:	Date:	date
Title:	Email:	Email

Email this recommendation to hlthethx@uw.edu, not to the applicant.