Reference for CPE Applicant You may use this page to submit a reference, at the request of a CPE applicant. Your reference may be sent via e-mail simply by clicking the SUBMIT button at the bottom of the page, or you may print the page and send it via US mail to: Chaplain Ralph Ciampa, Department of Pastoral Care, HUP Dulles One, 3400 Spruce Street, Philadelphia PA 19104. (Note that an e-mail submission is not electronically secure, if you have confidentiality concerns.) You should PRINT A HARD COPY FOR YOUR RECORDS. If you have questions about this form or procedure, call Chaplain Ciampa at 215-662-2591. Applicant's Name: Applicant Applying for: Please choose one Residency Externship (part time) Summer Internship Your Name: Your Address: Your Phone: Your E-mail: 1. How long have you known the applicant? 2. What is your relationship to the applicant? 3. Give a summary of the strengths and weaknesses you feel this applicant will bring into a training program for ministry? 4. How effectively have you seen the applicant work in a group setting? 5. Are you aware of any personal barriers that may make direct ministry to patients and staff of diverse backgrounds particularly difficult for the applicant? 6. (OPTIONAL) How would you describe the applicant's integration of spiritual and religious values? 7. Do you have any concerns about the applicant's reliability? 8. How would you assess the applicant's level of maturity and judgment, especially during crises or times of stress? 9. In your opinion, are there any barriers to the applicant's participation in structured academic settings requiring a moderately advanced level of communication skills? 10. Are there any other observations which would help us understand the applicant? May this reference be shared with the applicant? Yes     No