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Reference

The document is a reference form for applicants to the UVA Health Prince William Medical Center's Summer Teen Volunteer Program. It requires evaluators to assess the applicant's maturity, responsibility, and commitment through a checklist and open-ended questions. The completed form must be returned in a signed sealed envelope for submission.

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6 views

Reference

The document is a reference form for applicants to the UVA Health Prince William Medical Center's Summer Teen Volunteer Program. It requires evaluators to assess the applicant's maturity, responsibility, and commitment through a checklist and open-ended questions. The completed form must be returned in a signed sealed envelope for submission.

Uploaded by

CK
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UVA Health Auxiliary

UVA Health Prince William Medical Center

Teen Volunteer 2025 Summer Program Reference Form

Applicant’s Name _____________________________________ Date: _____________

The person named above has applied to UVA Health Prince William Medical Center for a volunteer position.
Participation in the Summer Teen Volunteer Program requires a high level of maturity, responsibility, and
commitment. Applicants are accepted based on their application, recommendations, and group interview.
Please take the time to honestly evaluate the above named applicant by (1) completing the check-list below
and (2) answering the questions on the reverse/added page of this form. Thank you in advance for your
time to evaluate this applicant. Also, please be sure to sign the reference form. A lack of signature
invalidates the form.

Your Name: __________________________________________ Your e-mail: ____________________

Your phone number ____________________ If we may call you, best time to call: __________________

Your relationship to the applicant: ____________________

Length of time you have known the applicant: ____________________

If you are a teacher, please indicate the subject(s) in which you taught the applicant. ________________

Evaluation Criteria for Ranking

To Observe
Opportunity
Frequently
Usually
Always

Rarely
Please rank this applicant using the criteria

No
listed below.

Applicant displays conduct appropriate to a setting.


Applicant works well with peers and adults.
Applicant completes assigned tasks.
Applicant accepts responsibility for assigned tasks
and personal behavior.
Applicant listens and follows instructions.
Applicant demonstrated effective oral communication.
Applicant is resourceful and self-reliant with new
situations
Applicant demonstrates respect for others, accepts
supervision, and treats others with kindness
Applicant acts appropriately in a given situation.
Applicant is punctual

Page 12 of 13
Applicant Name______________________ page 2 of 2

Please briefly answer the questions below.


1. If you were a patient or employee at a hospital, would you like this applicant to be
assigned to your area? If no, please explain.

2. To your knowledge, has this applicant been subjected to any disciplinary action? If
yes, please explain.

3. What characteristic(s) distinguishes this applicant from others?

4. Is there any additional information that may be relevant to this situation?

Important: When you have completed the reference form, please give back to the applicant in a signed
sealed envelope for submission. If you have any questions or concerns, please contact the UVA Health
Prince William Medical Center Volunteer Services office for the Summer Teen Program at 703-369-8173.

Evaluator’s printed name: ___________________________ ___________________________________


(First Name) (Last Name)

Evaluator’s signature: __________________________________________________________________

Page 13 of 13

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