SEXUAL HEALTH AWARENESS PEER EDUCATOR
S.H.A.P.E.

PERSONAL AND/OR CAMPUS REFERENCE

After the completion of the interview, each candidate selected will be asked to provide two references: one campus reference (i.e., employer, advisor, faculty/staff, RA, Greek House officer, etc.) and one personal reference (someone who knows you  well, NOT a family member). 

The reference forms will be mailed to selected applicants with their acceptance letter.  Acceptance to the SHAPE Program is conditional as both campus and personal references must be received in the Health Promotion Office within 2 weeks of the date on the acceptance letter.

Personal Reference or Campus Reference
(circle which type)

________________________________, a candidate for the S.H.A.P.E. position has included you as a reference on his/her application. Please complete and return this reference to Health Promotion, Room 268, Lafene Health Center by ____________________________. PLEASE DO NOT RETURN THIS REFERENCE FORM TO THE CANDIDATE. Confidentiality will be maintained to the maximum extent allowable by law.

Please rate the applicant based on the rating scale below

O - outstanding, MS - more than satisfactory, SAT – satisfactory,
NI – needs improvement, U – unsatisfactory, NO – not observed
O
MS
SAT
NI
U
NO
Dependability            
Confidentiality            
Ability to serve as a role model            
Time Management skills            
Balances academics vs. responsibilities            
Communication skills            
Stress management skills            
Objectivity skills            

How long have you known the candidate?  Years __________ Months ___________

How do you know the candidate? _______________________________________

How well do you feel you know the candidate?
Only casually __________ Moderately well __________ Very well _________

Please identify two (2) major strengths and two (2) major limitations for this candidate.

    Strengths (2)
  1.  
  2.  
    Limitations (2)
  1.  
  2.  

Although most respondents feel that the above questions are adequate reference, you may use the space below to write additional comments and/or attach additional sheets.

Reference Name: _______________________________ Date: _______________
(Attach business card if you know this candidate as an advisor, instructor, or employer.)

May we contact you for further questions? Yes ________ No ________

Phone: _________________________

THANK YOU FOR YOUR ASSISTANCE.

PLEASE RETURN BY ____________________________ TO:

Health Promotion
Lafene Health Center
Room 268
1105 Sunset Avenue
Manhattan, KS 66502