TEXAS WOMAN'S UNIVERSITY
School of Physical Therapy
APPLICANT RECOMMENDATION FORM
This form must be completed by a physical therapist who is licensed in the
U.S. or who graduated from an accredited physical therapy entry-level educational
program in the United States.
To the Applicant: Please complete the information at the top of the form
and give it to the physical therapist that will be supplying the remainder of
the information after you have completed 20 hours at this facility. Only
one Person at each facility may complete a form. Please make sure the name of
the physical therapist supplying the information is complete and legible.
Name of Applicant:
____________________________________________________________
Current Address:
____________________________________________________________
____________________________________________________________
Name and Title of Physical Therapist supplying the information (please print):
____________________________________________________________
Name / Title / License # and State
____________________________________________________________
Facility Name / Street Address
____________________________________________________________
City / State /Zip code / Phone
____________________________________________________________
Signature of Applicant / Date
Applicant: DO NOT write below this line. To be completed by only
one therapist at the facility.
To the Therapist: The individual named above has applied for admission
to the physical therapy program at Texas Woman's University. He/she has given
permission for you to provide reference type of information in order to complete
his/her application. The applicant must have completed a minimum 20 hours
of volunteer service or employment prior to your completing the reference.
Please complete the entire form. Each item should be rated and you are
encouraged to comment as you see fit. Please complete both sides of the
form and return the completed and signed form to the School of Physical Therapy,
Texas Woman's University, P.O. Box 425766, Denton, Texas 76204-5766 by the
application deadline of November 1. In the event that something should
happen to cause you to wish to alter this evaluation, please contact us at
940/898-2460.
Thank you for your assistance in providing needed information for this
applicant.
Rating scale:
5 One of best I have observed
4 Above average
3 Average
2 Below average
1 Major deficiencies
0 Not observed/Not applicable
1. Demonstrates a caring attitude toward others.
5__________4__________3__________2__________1__________0
2. Uses active listening skills.
5__________4__________3__________2__________1__________0
3. Expresses self and/or communicates orally with others.
5__________4__________3__________2__________1__________0
4. Uses appropriate non-verbal communication.
5__________4__________3__________2__________1__________0
5. Responds appropriately to both verbal and non-verbal communication from
others.
5__________4__________3__________2__________1__________0
6. Demonstrates emotional stability and maturity.
5__________4__________3__________2__________1__________0
7. Responds appropriately to persons in authority.
5__________4__________3__________2__________1__________0
8. Demonstrates dependability/reliability/promptness.
5__________4__________3__________2__________1__________0
9. Demonstrates flexibility.
5__________4__________3__________2__________1__________0
10. I would welcome this person as a colleague in the physical therapy profession.
_____Yes, without reservation
_____Yes, with reservation
_____No
_____No comment
11. Briefly describe why you feel this applicant should be admitted to the program,
over other applicants.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Applicant performed as:
_____Volunteer/Observer
_____Approximate number of hours
_____Date
_____Paid employee
_____Approximate number of hours
_____Date
____________________________________________________________
Signature
____________________________________________________________
Position/Title
____________________________________________________________
Area of Specialization/Type of Clinic
_______________
Date
Rev. 12/02
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