Chattanooga State
Community College
Pub. No. 11-70-204101-3-7/17/HAL-100-Chaanooga State is an AA/EEO employer.
Applicant Name: ________________________________________________
Applicant Signature: _____________________________________________
To the Applicant
Please have this form completed by your academic advisor, or a college instructor. If you are enrolled or have graduated
from a Radiologic Technology Program, or equivalent healthcare program, the Program Director or Clinical Coordinator
must complete this form. Please note that by signing this form, you are giving that person permission to complete an
evaluaon of you. This reference will become part of your program applicaon and will remain condenal.
To the Advisor/Instructor/Director/Coordinator
The individual listed above is applying to the Nuclear Medicine Technology Program at Chaanooga State Community
College. The Nuclear Medicine Selecon Commiee needs your input to assist with the student selecon process.
Please seal the completed reference form in an envelope before returning to the student. This form will be turned in
with the student’s program applicaon.
Please Rate the Applicant in the Following Areas
Grading Scale: 4 = Superior; 3 = Good; 2 = Average; 1 = Poor; 0 = Unacceptable; ½ points are acceptable (3.4, 2.5, 1.5, .5)
Circle the appropriate number for scoring:
Characterisc:
Academic
Potenal
Comm.
Skills
Dependability
/ Reliability
Emoonal
Stability
Judgment Leadership
Ability
Maturity Movaon Responsibility Self
Condent
4 4 4 4 4 4 4 4 4 4
3 3 3 3 3 3 3 3 3 3
2 2 2 2 2 2 2 2 2 2
1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0
Indicate your Overall Recommendaon of the Applicant
___ Strongly Recommend
___ Recommend
___ Recommend with Reservaons
___ Do Not Recommend
Reference Informaon
Name:_______________________________________ Phone Number: _______________________________________
Program/College/Department: _________________________________________________________________________
How long have you known this applicant? ________________________________________________________________
Evaluator Signature: ________________________________________________
Addional Comments: Please use back of form for any addional comments.
Academic Reference Form for Nuclear Medicine