University of Texas Medical Branch

Department of Clinical Laboratory Sciences

Galveston, TX 77555-1140

Specialist in Blood Bank Technology Program

Applicant Reference Form

(Insert applicant’s name) has applied for admission to the Specialist in Blood Bank Technology or the Masters in Transfusion Medicine Program at UTMB in Galveston, Texas. Please rate the following attributes of this applicant according to the scale below. A numerical score based on your responses will be used in our applicant evaluation process. You may provide comments in the spaces provided or record additional information on a separate page.

In each category, click the dropdown list to rate the applicant according to the following scale:

5: Excellent 4: Above Average 3: Average 2: Below Average 1: Poor

Time Management: Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Completes work or projects on time. Organized in work.
Comments:
Accuracy:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Performs tests and evaluates results accurately.
Comments:
Initiative:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Seeks to expand knowledge and experience; enthusiastically approaches problem-solving. Demonstrates supervisory skills.
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Cooperation:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Tactful, friendly, and responds well to constructive criticism. Works well with others.
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Communication:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Communicates effectively, both verbally and in writing.
Comments:
Judgment:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Correlates facts quickly, exercises sound judgment in making decisions.
Comments:
Emotional maturity and stability:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Works well in stressful situations; organizes and maintains composure under increased workload and assignments.
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Problem solving ability:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Analyzes situations and issues and comes to logical conclusions.
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Leadership / Supervisory ability:Select response5: Excellent4: Above average3: Average2: Below average1: PoorUnable to rate
Demonstrates ability to motivate. Follows through on actions.
Comments:
How long have you known the applicant and in what capacity?

Thank you for completing this reference. This information will be held in confidence.

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Name: / Date:
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Rev. 03-2016Page 1 of 2