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Student Appraisal Form

The Student Appraisal Form is an online form where faculty can submit information on students to the Office of Health Professions. This information is used to advise students as well as to compose letters of recommendation to health professional schools. Information submitted is confidential; however, the faculty member can voluntarily waive this right to confidentiality.

I hereby waive and relinquish any right of confidentiality.

yes

Applicant Name
	Last Name, First Name, Middle Name
Evaluator’s Name

Title/Position		Institution

Postal Address		City
State		Zip

In what capacity have you known the applicant?

	As a student in a large lecture course		As his/her employer
	As a student in a lab course		As an independent researcher under my direction
	As his/her academic advisor		As a student in a small class

Other

How long have you known the applicant?
Years		Months

The applicant ranks academically with other students taught in recent years as follows:
	Top 5%		Top 10%		Top 25%		Average		Below Average		Unable to Judge

What would be your attitude toward having this student in a responsible position under your direction?

Definitely would want him

Would be satisfied to have him

Definitely would not want him

Would want him

Would prefer not to have him

Unable to Judge

To your knowledge, has there ever been any disciplinary action involving this student which might indicate unsuitability for medicine?

Yes

Please provide a full explanation in Narrative Comments section

Part II
The Office of Health Professions would appreciate more detail about this student. Please write candidly about the student’s qualifications and potential for professional school as well as academic success. In describing such attributes as motivation, intellect and maturity, discuss both strong and weak points. 2 pages maximum

Part III

	Excellent 5	Good 4	Average 3	Fair 2	Poor 1
Intellectual Ability/Independence
Ability to communicate with others
Emotional Stability
Study Habits
Attendance
Comprehension
Accuracy/Attention to Detail
Maturity/Judgement
Motivation/Perseverance
Sense of Responsibility
Initiative/Class Effort
Cooperative Attitude
Ability to Work with Others
Leadership/Leadership Potential
Personal Appearance
Inquisitiveness
Assertiveness
Knowledge of Career
Integrity
Self-Understanding

1. Major Strengths of this Student

2. The applicant, in relation to perceived ability to successfully pursue a graduate or professional health program, is rated as follows:

Excellent

Good

Average

Fair

Poor

Unsatisfactory

3. This applicant is:

	Recommended Enthusiastically		Recommended With Confidence
	Recommended With Confidence		Recommended
	Recommended With Reservations		Not Recommended