You have been asked to serve as a faculty reference for a student who has applied for employment as a Nurse Extern at Dayton Children’s Hospital. We would appreciate your candid assessment of this applicant’s ability to function personally and professionally as a member of our team. Any information you provide will be considered confidential. References must be submitted by January 3, 2025 at 12:00 noon.

Question Title

* 1. Date

Date

Question Title

* 2. Extern Name

Question Title

* 3. In what capacity have you known the applicant?

Question Title

* 4. Please rate the applicant's performance as a student nurse in the following categories:

  Exceeds Requirements:  Good Judgment Meets Requirements:  Satisfactory Judgment Needs Improvement:  Judgment not always sound Not Applicable:  Unable to assess
Quality of Nursing Care - Safety/Timeliness
Critical Thinking - Applying scientific principles
Leadership Skills - Assertiveness vs. Aggression
Initiative - Self directed/Good use of time
Flexibility - Adjusts to changes in assignments
Reaction under Pressure - Speaking with interdisciplinary team/Changes in patient's condition
Accountability - Honesty/Dependability

Question Title

* 5. Please rate the applicant's performance as a student nurse according to the descriptions given:

  Remarkable, high level of concern and service Conscientious, pleasant and interested Sometimes indifferent Consistently indifferent
Attitude towards patients and families

Question Title

* 6. Please rate the applicant's performance as a student nurse according to the descriptions given:

  Considerate, voluntarily helpful Cooperative, helps only when asked Inconsistently cooperative Inconsiderate, works poorly with others
Attitude toward peers, faculty and staff

Question Title

* 7. Recommendation

Question Title

* 8. Attendance - please check all appropriate boxes

Question Title

* 9. Other remarks:

Question Title

* 10. Your information

Question Title

* 11. Electronic Signature - by typing my name below, I verify that the information provided above is accurate and true to my experience with this student.

If you have any questions regarding the Faculty Reference form, please contact Gay Gauder in Nursing Administration at gauderg@childrensdayton.org or by phone 937-641-5847. Fax 937-641-5021

T