Stevenson University Undergraduate Nursing Program

Stevenson University Undergraduate Nursing Program Reference Form for Transfer Students

This form is to be used by transfer students seeking admission to the pre-licensure (i.e., “traditional”) undergraduate Nursing Program in the School of the Health Professions (SHP) at Stevenson University to submit references with their application. Students interested in the RN to BS or master’s degree programs in nursing should use the recommendation form provided by the School of Graduate and Professional Studies (GPS). Applicants should complete Sections 1 and 2 of this form electronically, and then email the form to the college faculty member providing the reference.

SECTION 1: APPLICANT INFORMATION

Name of Applicant (Last, First, Middle): Click here to enter full legal name.

Institution Currently Attending: Click here to enter name of institution currently attending.

Email Address: Click here to enter email address.

SECTION 2: FERPA NOTICE AND WAIVER

The Family Educational Rights and Privacy Act of 1974 (FERPA)

Stevenson University informs students of the Family Educational Rights and Privacy Act of 1974, as amended. This Act, with which the institution intends to comply fully, was designated to protect the privacy of education records, to establish the rights of students to inspect and review their educational records, and to provide guidelines for the correction of inaccurate or misleading data through informal and formal hearings. Students also have the right to file complaints with The Family Educational Rights and Privacy Act (FERPA) office concerning alleged failures by the institution to comply with the Act. Local policy, which explains in detail the procedures to be used by Stevenson University for compliance with the provision of the Act, is posted on the University Website, the Academic Affairs portal site, and in the Office of the Registrar. Questions concerning the Family Educational Rights and Privacy Act should be directed to the Registrar.

☐ By checking this box, I acknowledge that I have read and understood the notice regarding the Family Educational Rights and Privacy Act of 1974.

In connection with my application to the Stevenson University Nursing Program (check one statement),

☐ I hereby voluntarily waive and relinquish any right of access to this recommendation. ☐ I retain my right of access to this recommendation.

By typing my name below, I give permission for the individual named in Section 3 below to communicate with Stevenson University. It is my understanding that the evaluation will be based upon the individual’s knowledge of my academic performance and character traits. He/She has my permission to include my grades, grade point Nursing Reference Form - SHP Admissions Rev. 8/5/16, Page 1 average, class rank, and any information I have provided to him/her in my biographical sketch, and to use gender-specific pronouns. I acknowledge that sending this completed form via email will serve as an electronic validation of my signature.

Applicant’s Name: Click here to enter full legal name.

Date: Click here to enter date.

SECTION 3: REFERENCE FROM COLLEGE FACULTY

To be completed by the faculty member providing the reference:

Stevenson University is interested in your assessment of the applicant’s professional promise for Nursing. Your answers to the questions below may be typed into this form, or you may attach your answers on business letterhead. Regardless of whether you attach a letter or answer the five questions directly on this form, please complete the ranking chart below. Once complete, please email this form directly to [email protected] or return it in a sealed envelope with your signature across the back flap to Stevenson University Admissions Office, Garrison Hall, 100 Campus Circle, Owings Mills, MD 21117-7804.

☐ I have attached a letter of reference that addresses these five questions. (Proceed to the ranking chart below.)

1. How long and in what capacity have you known the applicant?

Click here to enter text.

2. What course(s) did the applicant take with you?

3. What are the applicant’s strengths?

4. What are the applicant’s weaknesses or areas in need of improvement?

5. What is the applicant’s potential to succeed in a nursing program?

Please complete the chart below:

Above Below Average Excellent Average Average Unable to Applicant Characteristics (Top 25- (Top 10%) (Top 10- (Bottom assess 50%) 25%) 50%) Demonstrated leadership ☐ ☐ ☐ ☐ ☐

Nursing Reference Form - SHP Admissions Rev. 8/5/16, Page 2 Judgment and maturity ☐ ☐ ☐ ☐ ☐ Ability to work with others ☐ ☐ ☐ ☐ ☐ Intellectual capability ☐ ☐ ☐ ☐ ☐ Science knowledge ☐ ☐ ☐ ☐ ☐ Critical thinking skills ☐ ☐ ☐ ☐ ☐ Organizational skills ☐ ☐ ☐ ☐ ☐ Oral and written communication ☐ ☐ ☐ ☐ ☐ Quantitative ability ☐ ☐ ☐ ☐ ☐ Ethics and Integrity ☐ ☐ ☐ ☐ ☐

Name: Click here to enter full name.

Title: Click here to enter title.

Institutional Affiliation: Click here to enter institutional affiliation.

Institutional Address: Click here to enter Street Address. Click here to enter City. State. Zip Code.

Phone Number: Click here to enter phone number. Email Address: Click here to enter email address.

If submitting reference via email to [email protected], sign here:

By typing my name below, I certify that I am the individual named above, and that the information I have provided regarding the applicant named in Section 1 is accurate and truthful. I acknowledge that sending this completed form via email will serve as an electronic validation of my signature.

Name: Click here to enter full legal name.

Date: Click here to enter date.

If submitting reference via U.S. Mail, sign here:

By signing below, I certify that the information I have provided regarding the applicant named in Section 1 is accurate and truthful.

______Signature Date

Mail signed form in a sealed envelope with your signature across the back flap to:

Stevenson University Admissions Office Garrison Hall 100 Campus Circle Owings Mills, MD 21117-7804

Nursing Reference Form - SHP Admissions Rev. 8/5/16, Page 3