Apllicant's nameName of person completing this form

To the Applicant: Letters are required from three or more persons who know your academic and personal abilities well. The most preferred letters are from former college instructors in Psychology or from mental health professionals with whom you have worked. For the convenience of the person completing this form, you should include a stamped, addressed envelope.

Under the federal Family Educational Rights and Privacy Act of 1974, students are entitled to review their records, including letters of recommendation. However, those writing recommendations and those assessing recommendations may attach more significance to them if it is known that the recommendations will remain confidential. (Confidential means that the student formally gives up the right to see the recommendation.) Under this law, you may choose to waive (give up) your right to see this recommendation, or you may decide not to waive your right to see this recommendation.

I waive my right to review                I do not wave my right to review this
      this recommendation.                           recommendation.

___________________________        ________
APPICANT'S SIGNATURE                      DATE            
 Form should reach Washburn no later than March 15.

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1. I have known the applicant for years, months.
2. I know the applicant slightly fairly well very well.
3. I have known the applicant:

   As an undergraduate	As an undergraduate assistant
   As a graduate student	As a teaching assistant
   As an advisee	other

4. The applicant has taken:
   none of my classes one of my classes two or more of my classes
5. Indicate the population with which the applicant is being compared in this rating:
   High school students whom I have taught or known
   Undergraduate students whom I have taught or known
   Graduate students whom I have taught or known
   All students, graduate and undergraduate, whom I have taught or known
   Colleagues with whom I have worked
6. Is the applicant's academic potential greater or less than that indicated by his/her grades?
   much less somewhat less equal somewhat greater much greater
   cannot determine
   Please explain/clarify:
   
7. How would you rate the applicant's potential for chinical or counseling work?
   poor fair good excellent cannot determine
8. Global Ratings: Compared to the population in Item 5, rate this applicant on each characteristic.

   Characteristics	Lower 50%	Upper 50%	Upper 25%	Upper 10%	Upper 5%	No basis of judgement
   Academic Ability
   Analytic Ability
   Psychology Knowledge
   Oral Expression Skills
   Written Expression Skills
   Research Skills
   Carefulness in Work
   Emotional Maturity
   Independence and Initiative
   Professional Commitment
   Desire to Achieve
   Social Awareness and Concern
   Ability to Work with Others
   Potential for Success

9. Indicate the strength of your overall endorsement of the applicant.
   not recommended   recommended w/ some reservations  recommended
   highly recommended
10. The space below is supplied for any additional information you may wish to provide, such as explanations of any of the global ratings checked. The most important information you can provided about this applicant is information that is not reflected in the applicant's transcript and test scores (i.e., work done outside of class and other experiences you believe are related to success in graduate school). Please attach additional pages if necessary.
    
    

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Signature of Person Completing this FormTitle

________________________________________     _____________________________________
Name (Print)Institution or Affiliation

Please PRINT OUT this online form. If this form does not print with your options marked, please print out a blank version and fill it in by hand. Send completed form to:
Admissions Committee
Department of Psychology
Washburn University
Topeka, KS 66621