Peconic Bay School of Radiologic Technology Classroom: 4 West Second Street, Lower Level, Riverhead, New York 11901 Mailing Address: 1300 Roanoke Avenue, Riverhead, New York 11901 (631) 548-6173 Email: xrayschool@pbmchealth.org Name of Applicant (Print Clearly): _______________________________________________________________________________ Name of Reference (Print Clearly): _______________________________________________________________________________ _____ I am this applicantÕs employer/supervisor. _____ I am this applicantÕs instructor/professor or former instructor/professor. _____ This applicant has worked under my supervision from _______ to _________. TO THE APPLICANT: Fill in the information above. For the convenience of your reference, please include a SELF-ADDRESSED STAMPED ENVELOPE with this form. Your reference should return their LETTER OF RECOMMENDATION to you to include in your application packet. In accordance with the provisions of the Family Educational Rights and Privacy Act of 1974, P.L. 93 Ð 390 (as amended), with specific reference to Section 438 (a)(1)(B) and Subtitle A, sections 99.7, 99.11, and 99.12, I do _____ I do not _____ waive my right to access to and review of this form. ___________________________________________________ __________________ Signature of Applicant Date TO THE REFERENCE: The applicant named above is applying for admission to Peconic Bay School of Radiologic Technology. We are interested in obtaining information that will aid us in selecting capable students. It is important that students who are selected be able to complete their academic work successfully, and also possess the personal qualifications essential to become competent professionals. PLEASE COMPLETE BOTH PAGES! The applicant has selected you as someone who can give us such as appraisal. We would appreciate your candid evaluation of the applicantÕs qualifications for acceptance to the program. The pending application will be considered incomplete until your response is received. 1. PERSONAL & PROFESSIONAL APPRAISAL: (Please evaluate the applicantÕs qualifications and characteristics by checking the appropriate spaces below.) Qualifications/Characteristics SUPERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE N/A Intellectual Ability Reliability Sense of Responsibility Industry & Perseverance Ability to Work Independently Ability to Adapt to New Situations Ability to Work With People Ability to Analyze Problems & Solve Them Correctly Oral Communication Written Communication Emotional Stability Leadership Potential TO THE REFERENCE: In addition, please complete the following information. 2. ACQUAINTANCE WITH APPLICANT: How long and in what capacity have you known this applicant? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. COMMENTS: In the space below (use an extra sheet if needed), please add any descriptive comments that will aid in providing a complete picture of the applicantÕs abilities and potential as a student and health care professional. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. RECOMMENDATION FOR ACCEPTANCE: ______ Strongly Recommend ______ Recommend ______ Recommend with Reservations ______ Do Not Recommend PLEASE TYPE OR PRINT Your Name: ________________________________________________ Professional Credentials: ___________________ Title: ______________________________________________________________________________________________ Organization: _______________________________________________________________________________________ Address: ___________________________________________________________________________________________ City: _________________________________________ State: ____________ Zip Code: _____________ Telephone Number: _________________________________________________________________________________ Date: ____________________________ Signature: ________________________________________________________ PLEASE NOTE: It is not possible to thank each individual personally for completing a recommendation form. We want you to know, however, that we are aware of the time required and both we and the applicant are most appreciative of your response. If attaching a separate Letter of Recommendation, please state on this form in #3-Comments, but please do complete the #1-Personal & Professional Appraisal on page 1.