You have been identified as a REFERENCE

In advance, thank you for your attention and response to this survey. Our Registered and future Registered Nurses within the District 5 region greatly appreciate your kind words and honest recommendations. 

Please follow the directions for the reference below. Should you encounter difficulties, reach out to

The applicants have a tight timeline for submission. Once their entire application package is received, surveys are then routed to their references. It is TNAD5's goal to provide references with a minimum of 2 weeks to complete the online reference form. 

If you are unable to complete the online reference, please allow us to accommodate you in a different manner via telephone, paper, virtual or other method of reference delivery. 

TNAD5 endeavors to create a more accessible platform for students, enabling more applicants opportunity to apply and also making the process less burdensome on potential reference sources, such as yourself. 

On behalf of the board of TNAD5, our gratitude is with you as you complete this reference. 

Yours in service, 

Texas Nurses Association District 5 
Board of Directors 2019-2020

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* 1. Please provide your contact information.

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* 2. How many years have you known the scholarship applicant?

0 25 50
i We adjusted the number you entered based on the slider’s scale.

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* 3. Please describe your relationship with the applicant.

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* 4. Please rate the applicant on the following qualities intrinsic to nursing professionalism. 

Based on your first-hand experiences with the applicant, on a scale of 0 to 5, how would you rate the applicant?

0 - no experience / reference has no first-hand experience with applicant on topic
1 - applicant has minimal experience and is considered a novice 
2 - applicant has minimal experience but is gaining exposure and seeking opportunities to grow
3 - applicant has moderate experience and continues to advance 
4 - applicant is proficient and demonstrates a broad degree of independence and collaboration
5 - applicant may be described as a "visionary," "leader," "thoughtful," innovator," "self-aware," "accountable," and demonstrates an eagerness to learn, give back, advance his/her education or is pursuing a terminal degree (PhD, DNP or other doctorate) 

  0 1 2 3 4 5
Servant leadership
Service to community
Academic excellence
Research - interest in OR actively pursuing
Technology - Meaningful use
Business alignment

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* 5. Please discuss a work, academic or volunteer experience in which the applicant encountered a situation that was difficult to navigate; answer the following to the best of your abilities: 
what was the situation
the applicant's involvement
what did the applicant do in that situation/how did he/she behave
what was the result

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* 6. Thank you for your feedback.
Please add any additional details you may find relevant for the scholarship committee to use in selecting the 2020 recipients.

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* 7. Your electronic signature acts as the equivalent to your manual signature and indicates that you validate the information provided is factual and accurate in reference to this applicant and that you understand the following:  

Misinformation may result in applicant disqualification, partial or total scholarship fund cancellation. 

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