Peer Health Educator Professional Reference Form

The mission of the Peer Health Education Program is to support the well-being of SJSU students. Our primary objective is to recruit, train and organize students to conduct health education and outreach. We aim to increase students’ awareness and responsible decision-making regarding health and wellness. We welcome all SJSU students’ skills, creativity, questions, ideas and passion.

Selection for PHE is competitive. Wellness and Health Promotion is looking for students who have the motivation, maturity, and intellectual capacity to be a role model, advocate, and educator for their peers.

Instructions:
Please help us learn more about this student by answering the following questions. We would appreciate any additional insights not covered by these questions. This reference form is due by 4/14/17 at 5pm.

Name of Student Applicant
Your answer
Reference Name
Please write your first and last name here.
Your answer
Job Title
Your answer
E-Mail Address
Your answer
Work Phone Number
Your answer
What is your relationship with the student applicant?
ie: Supervisor, Professor, etc.
Your answer
How long have you known the applicant?
Your answer
Please rate the applicant on their attributes and skills using the scale below.
4-Exceeds Expectations 3-Meets Expectations 2-Below Expectations 1-Does Not Meet Expectations
1
2
3
4
Unable to Evaluate
Ability to Work with Others
Communication Skills
Presentation Skills
Maturity
Motivation
Attitude
Responsibility
Time Management
Problem Solving
What two strengths does the applicant possess and how will these strengths contribute to the mission of the Peer Health Education Program?
Please refer to the top of the reference form for the PHE mission.
Your answer
Is there anything else you would like to share about the applicant?
Your answer
Overall Recommendation of the Candidate.
Submit
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