Dental Hygiene Program Recommendation Form

Name of Applicant

To assure that your records are held in compliance with the law as stated below*, please check one:

I GIVE UP my right to access of this form. I DO NOT GIVE UP my right to access of this form.

Applicant Signature Date

The above named applicant is a candidate for admission to the Blinn College Dental Hygiene Program and has named you as a reference. Your comments will be used only by the admissions committee of the dental hygiene program to assist them in arriving at a better understanding of this applicant. Your cooperation in completing this form will assist both the applicant and the Dental Hygiene Program.

*Please Note: FERPA grants a student/applicant access to his/her records as maintained by the department of Dental Hygiene at Blinn College. It also grants a student/applicant the right to waive access. See above for the student’s/applicant’s choice regarding confidentiality.

I have known the applicant in the following capacity and location:

I have known the applicant for years months.

I would evaluate the applicant as follows:

Area of Evaluation	Excellent	Above Average	Average	Below Average	Not Known
Attitudes toward others (caring, respect)	□	□	□	□	□
Ability to work with others	□	□	□	□	□
Ability to communicate orally	□	□	□	□	□
Ability to communicate in writing	□	□	□	□	□
Independence	□	□	□	□	□
Initiative	□	□	□	□	□
Ability to accept responsibility	□	□	□	□	□
Presentation of self (poise, courtesy, language)	□	□	□	□	□
Potential for growth	□	□	□	□	□

RECOMMENDATION:

Strongly Recommend Recommend Recommend with Reservation Not Recommend

Comment(s):

Signature Date Position

Address

Telephone