DVUSA Reference Form

Reference Form Instructions

This online reference form has a total of four sections.

Your submission may be shared in its entirety with potential communities and placement sites that are applicable to the applicant, however, we will disclose any personal information on a “need to know basis.” Please know that the applicant will not see nor have access to your submission.

Should any questions arise, please contact the DVUSA office at 708-524-5985.

Section #1

Applicant's Name *

How long have you known the applicant? *

What is your relationship to the applicant? *

Section #2:

Character Portrait: On a scale of 1 - 5 (five being highest), please rate the applicant according to the following qualities (indicate "UK" if unknown). There should be a balance in your responses.

Creativity *

Leadership *

Social Skills *

Adaptability *

Self-esteem *

Cooperation *

Organization *

Dependability *

Assertiveness *

Self-discipline *

Common Sense *

Sense of humor *

Physical Fitness *

Decision-making *

Dealing with stress *

Ability to work alone *

Communication skills *

Openness to new ideas *

Acceptance of criticism *

Sensitive to other cultures *

Ability to work with others *

Section #3:

Describe the applicant’s personality, commenting on at least two of the traits above. *

Assess the applicant’s work skills. *

Assess the applicant’s interpersonal skills and ability to live with others. *

Comment on the applicant’s spiritual life. *

Do you have any reservation about this applicant? *

Any additional comments?

Section #4:

I attest that all information contained in this reference submission is true to the best of my knowledge.

I aslo attest below that this submission has been completed solely by me.

Name: *

Address: *

Day-time telephone number: *

Email address: *

Electronic signature: *

Date: *