[DC GOVERNMENT] DC HPLRP Section II Recommendation Form

DC HPLRP Section II Recommendation Form

DC HEALTH PROFESSIONAL LOAN REPAYMENT PROGRAM APPLICATION

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

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.

Title

Phone Number

In what capacity do you know the applicant?

Current supervisor

Former supervisor

Professor

Other

How long have you known the applicant (approximate)? (Include Number of Years and Months)

What are the applicant's greatest strengths?

Can you identify any characteristics of the applicant that might limit their ability to provide 40 hours per week of clinical care for a minimum of two years?

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

Explain why you gave a score of 3 or less on any characteristics:

Recommender’s Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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