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DC HPLRP Section II Recommendation Form


DC Department of Health
Health Care Access Bureau
Health Professional Loan Repayment Program
899 North Capitol Street NE, 3rd Floor
Washington, DC 20002
P: (202) 442-5892 F: (202).442.4948

Section II: DC HPLRP Recommendation Form (This is the second part of three sections that make up the DC
HPLRP Application)

Recommendation forms must be completed by professional references; at least two references must be the applicant’s current or former supervisors.

Part A: Applicant Information (to be completed by applicant)/ Or on behalf of the applicant

Full Name

Part B: Recommender Information (To be completed by the recommender)

The individual listed above is applying to the DC Health Professional Loan Repayment Program (HPLRP). This form is confidential and will not be released to the applicant.

Recommender's Name

Full Address

In what capacity do you know the applicant?

Please rate the applicant relative to other individuals you have known in the same capacity by checking the appropriate number on the rating scales corresponding to each characteristic below (1 = lowest; 5 = highest):

A. Demonstrates and understands the need to provide care to the underserved

B. Demonstrates knowledge and acceptance of cultural diversity

C. Possesses strong interpersonal skills

D. Understands the health care delivery system

E. Exercises maturity in relating to patients and in making decisions

F. Ability to adapt and/or be flexible when relating to others on a professional basis

Recommender’s Signature

Choose how to sign

Full Date

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