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The information you provide will be maintained in a confidential file and reviewed only by Upward Bound central staff personnel. No applicant will be selected or rejected on the basis of a single reference appraisal. To help you understand the job the applicant seeks, please read the position description. We solicit your honest opinion of the applicant’s abilities and value the time you spend in completing this reference. Thank you very much for your assistance.

* Applicant Name

* Your Name

* Relationship to applicant (employer, teacher, etc.)

Your position/title

Your Employer

Your address

* Your phone number

KNOWLEDGE OF APPLICANT How long have you known the applicant?

Describe the context in which you have known the applicant

WORK PERFORMANCE How competent has the applicant shown him(her)self to be in school, on a job or project, or in a position of responsibility?

Please comment on your response giving specific examples, if possible.

HUMAN INTERACTION SKILLS An Upward Bound staff member must work effectively with other staff members and with students from a variety of social and economic backgrounds. How would you rate the applicant on his/her ability to contribute positively in this context? Outstanding (highly effective in interpersonal relationships, works well individually and in groups, can lead or follow as the situation demands, strong communication skills, very adaptable to circumstances) Good (adaptable, has good communication skills, is dependable and responsible, would be an asset to the work setting described) Average (has average skills relative to others in age group) Below Average (applicant may encounter difficulties in the setting described, communication skills and maturity are below average for age group) Poor (difficulties in interpersonal relationships, not suited for a position of this nature)

Please comment on your response giving specific examples, if possible.

EMOTIONAL MATURITY Throughout the six-week program, staff members are expected to function well--assessing situations and making appropriate decisions--even under stress. They must remain flexible to lead or follow directions based on the prevailing circumstance and must be open to offer and receive constructive feedback in a mature manner. They will often be challenged to move beyond their normal comfort zones. How would you rate this applicant with these conditions in mind? Outstanding (exceptionally mature and stable, can work well under stress, open to feedback, insightful, emotionally healthy, fun to be around) Good (a mature and emotionally stable person, should meet challenges and expectations in a positive manner that inspires growth) Average (average in maturity and stability for a person his/her age) Below Average (there is reason to question whether the applicant can contribute in this work setting at his/her current emotional maturity level) Poor (applicant is unsuited to work effectively in the work setting and is even likely to have a negative effect upon students and staff)

Please comment on your response giving specific examples, if possible.

Overall Recommendation/Additional Comments I recommend the applicant without reservation. I recommend the applicant as a good prospect for your staff. I have concerns about the applicant's ability to work effectively in this setting. I have significant concerns about the applicant's ability to work effectively in this setting. I feel the applicant is unsuitable for working with high school students .

Describe any notable abilities, interests, skills, or experiences that would further enhance the applicant’s ability to work in this setting.

Describe any reservations or potential weaknesses you perceive with regards to the applicant.

Would you like us to call you to discuss this applicant more thoroughly? Yes No

Please copy the word in the above image.