ACADEMIC REFERENCE FORM
Applicant Name:
Applicant e-mail:
APPLICANT: A professor or official academic advisor should complete the reference section. This person should be someone who is familiar
with your work and academic potential. HRTP requires only one reference; please do not submit additional references as they will not be reviewed or
influence your acceptance into the program.
REFERENCE: HRTP serves as the principal mechanism for placing undergraduate, graduate, and professional students in public health
internships at the New York City Department of Health and Mental Hygiene (DOHMH). The goals of HRTP are to orient the student to principles
and practices of public health planning, research, evaluation and administration; broaden concepts of public health by increasing awareness of needs,
challenges and career opportunities in the field; and assist DOHMH in recruiting skilled candidates with proven potential.
Students participating in HRTP work on current, relevant public health issues under the close supervision of experienced professionals. The students
are expected to apply skills learned in the classroom to practical problems as well as learn new critical skills through their internship. Students also
get first-hand experience working within a public health agency. Your evaluation of the student plays an important part in the selection process. As
such, we ask that you evaluate not only the student’s academic ability, but also his or her maturity and ability to work within a professional setting.
Reminder: for a complete application package, we ask that you complete this reference form and attach a letter of recommendation on your
organization’s letterhead.
Name:
Title:
Institution:
Department:
e-mail:
Phone Number:
1. Please describe briefly, how long you have known the applicant and in what capacity?
2. In comparison with other students you have known; please rate the applicant on the following characteristics:
Average
Poor
Unknown
Initiative
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Written Communication
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Verbal Communication
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Ability to synthesize material
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Ability to acquire new skills
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Personal Relationships
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Maturity and Dependability
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Professional Demeanor
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Overall Assessment
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3. I would ☐ would not ☐ select this student to work under my supervision.
IMPORTANT! Please attach a Letter of Recommendation on official letterhead with this form. You may submit this form and the letter of
recommendation to [email protected]
or via mail to HRTP: A Public Health Internship Program at NYC DOHMH 42-09 28
th
St., CN#65, Queens,
NY 11101, or in a sealed envelope to the applicant.
Signature:
Today’s Date:
Updated 10.2013
HRTP: A Public Health Internship Program at the New York City Department of Health and Mental Hygiene
42-09 28
th
St., CN#65, Queens, NY 11101-4132 • e-mail: [email protected] • url: http://www.nyc.gov/health/hrtp