University of Pittsburgh Dental Hygiene Application

Personal Evaluation:
Reference Code (Please enter the reference code given to you by the applicant):
   
Applicant's Last Name:
   
Applicant's First Name:
   
Applicant's Middle Initial:
   
How Long have you known the Candidate (Number of Years and Months) ?
   
In what capacity have you known the candidate?
   
Please rank this individual with respect to all characterisitics. If you have no basic for evaluation of any of the following characteristics, please indicate by (NA) not applicable.
   
1. Emotional Maturity
   
2. Willingness to cooperate
   
3. Initiates Activities
   
4. Self-Motivation Perseverance
   
5. Seeks Responsibility
   
6. Accepts Accountability for Actions
   
7. Conversation and Communication skills
   
8. Consideration for others
   
9. Subordinates self-interest for the welfare of the group or task
   
10. Conduct Sets a good example
   
11. Innovative in approach to tasks
   
12. Understands and grasps concepts
   
13. Ability to express self in writing
   
If you have observed any limitations in the candidate (physical, mental or emotional). Please indicate and explain.
   
Would you please make any statement you feel will help the commitee appraise this candidate
   
Please enter your name, position and address and telephone number
   
Date of Evaluation (mm/dd/yyyy):