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If this is a medical emergency, please call 911.

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First Name Last Name What has been the nature and duration of your relationship with this applicant? Do you feel that within the boundaries of a student nurse, this nurse has provided care that is safe and effective? Do you feel this applicant has the potential to develop critical decision-making skills? Do you feel this applicant has the potential to develop the leadership skills of a professional registered nurse? Please rate this student regarding their academic performance in his/her graduating class: Please rate this student regarding their level of leadership in his/her graduating class: Please rate this student regarding their level of maturity in his/her class as a whole: Please rate this student regarding their level of integrity in his/her class as a whole: Please rate this student regarding their level of ability to relate to his/her peers: Please rate this student regarding their level of ability to relate to those in authority: Please rate this student regarding their level of ability to accept responsibility: Please rate this student regarding their level of ability to accept constructive criticism: Please rate this student regarding their level of ability to be self directed. Do you recommend this person for admission? Additional comments: (Such as strengths, weaknesses or other information which the information which we should consider in making this decision:

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