Phs-1813

PHS-1813
Rev. 12/16

FORM APPROVED:
OMB No. 0937-0025
Exp. Date: 12/31/2019

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
Division of Commissioned Corps Personnel and Readiness
Recruitment Branch
1101 Wootton Parkway, Suite 100
Rockville, MD 20852

REFERENCE REQUEST FOR APPLICANTS TO THE
PUBLIC HEALTH SERVICE COMMISSIONED CORPS

To be completed by the applicant:
Applicant’s Name (Last, First, Middle Initial)

If the reference knows you -- the Public Health Service Commissioned Corps
applicant -- by any other name, e.g., maiden name, please indicate that name
here:

Only other names the applicant has used.

Your name has been given as a reference by the individual identified above who has applied for appointment to the Public Health
Service Commissioned Corps.
We would appreciate your frank and objective consideration of the requested information. To help us determine whether this person
is loyal, trustworthy, and of good character, we ask that you answer all questions on the front and back of this form as fully and
specifically as you can. The information you provide will be disclosed to the person identified above if he or she should so request.
The promptness of your reply will aid us greatly in our evaluation of this applicant. The information furnished by former supervisors,
employers, or college deans with the same or related background provides valuable information for use in evaluating applicants.

1. PERIOD OF ASSOCIATION

2. PROFESSIONAL RELATIONSHIP TO APPLICANT (CHECK APPROPRIATE BOXES.)

From
To
(MM/YYYY)

EMPLOYER

TEACHER

FACULTY ADVISOR

SUPERVISOR

DEAN

OTHER (SPECIFY)

3. EVALUATION OF APPLICANT (PROVIDE ANY DETAILS IN SECTION 7.)
ELEMENTS

OUTSTANDING

BETTER THAN
AVERAGE

AVERAGE

BELOW AVERAGE

NO BASIS
FOR JUDGMENT

PRODUCTIVITY
ABILITY TO WORK INDEPENDENTLY
INITIATIVE
APPLICATION OF SKILLS AND KNOWLEDGE
CAPACITY FOR DEVELOPMENT
ATTENDANCE
DEPENDABILITY IN CARRYING OUT ASSIGNMENTS
ABILITY TO WORK WITH AND FOR OTHERS
FLEXIBILITY -- ADAPTABILITY
ABILITY TO SOLVE PROBLEMS -- RESOURCEFULNESS
ORIGINALITY
JUDGMENT
ABILITY TO COMMUNICATE (ORAL/WRITTEN)
SUPERVISORY ABILITY

(Continue on reverse side)

PSC Publishing Service (301) 443-6740

EF

Applicant’s Name:
(Last, First, Middle Initial)

4. APPLICANT IS BEST SUITED FOR WHAT SPECIALIZATION, FIELD, OR POSITION

5. DO YOU KNOW OF ANY LIMITATIONS OR OTHER INFORMATION WHICH MIGHT IMPACT ON THE EFFECTIVENESS OR STABILITY OF THIS PERSON?
(Training, Personality, Emotional, Ethical)
NO

YES (Give Details in this Space)

6. WOULD YOU BE WILLING TO EMPLOY OR RE-EMPLOY THIS PERSON IF YOU HAD AN OPENING REQUIRING THE GENERAL PROFESSIONAL LEVEL AND
PROFESSION OF THIS INDIVIDUAL?
YES (IN WHAT CAPACITY?)

NO (GIVE REASONS)

7. COMMENTS (Please use this space to supply any further information, comments from section 3 and/or evaluation.)

8. SIGNATURE

12. INSTITUTION OR FIRM ADDRESS (Include ZIP Code) (Do not attach business
cards)

9. NAME (Type or Print)

10. TITLE OR POSITION

PHS-1813
Rev. 12/16

11. DATE

Telephone No.

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Ext.