Health Partners Advanced Practice Clinician Fellowship

Applicant's Name*

Applicant's Program*

Reference provided by*

Present Position*

Institution*

Email*

Phone*

A. Background Information

1. How long have you known this applicant?*

2. Nature of contact with applicant?*

3. If this applicant rotated in your department, what grade was given?*

Honors
High Pass
Low Pass
Fail

4. What date(s) did the applicant rotate at your institution?

Total number of students last year*

Honors*

Please enter a number from 0 to 100.

Excellent*

Please enter a number from 0 to 100.

Satisfactory*

Please enter a number from 0 to 100.

Unsatisfactory*

Please enter a number from 0 to 100.

Total

Should equal 100%

B. Qualifications for chosen fellowship.

Compare the applicant to other applicants/peers in your department.

1. Commitment to your department. Has carefully thought out this career choice.*

Outstanding (top 10%)
Excellent (top 1/3)
Very Good (middle 1/3)
Good (lower 1/3)

2. Work ethic, willingness to assume responsibility*

Outstanding (top 10%)
Excellent (top 1/3)
Very Good (middle 1/3)
Good (lower 1/3)

3. Ability to develop and justify an appropriate differential and a cohesive treatment plan.*

Outstanding (top 10%)
Excellent (top 1/3)
Very Good (middle 1/3)
Good (lower 1/3)

4. Communication Skills*

Superior
Excellent
Adequate
Poor

5b. Given the necessary guidance, what is your prediction of success for the applicant?*

Outstanding
Excellent
Good

C. Global Assessment

1. Compared to other NP/PA student/graduate candidates you have recommended this candidate is ranked as*

Outstanding (top 10%)
Excellent (top 1/3)
Very Good (middle 1/3)
Good (lower 1/3)

Total number of letters of recommendation written last year*

Total number recommended as such last academic year*

D. Written Comments

STUDENT HAS WAIVED RIGHT TO SEE THIS LETTER

YES
NO

ENTER YOUR FULL NAME AS YOUR SIGNATURE*

Letter of Reference

Letter of Reference