# ![](media/image1.png){width="1.25in" height="0.7916666666666666in"}Indian Health Service \-- Division of Oral Health

801 Thompson Ave. Suite 335 Rockville, Maryland 20852

800-IHS-DENT  fax 301-594-6610

### Dental Externship Candidate Reference Check-sheet

***Instructions: Extern Applicant**-please fill in your name, dental
school, and projected graduation date and give to your **Reference** to
fill out. Collect the sealed envelope with the **Reference's** signature
over the seal to be included in your application packet to be mailed to
your preceptor at the site that selected you. **3-4 References will be
required.***

**Instructions: Reference**-please fill out this reference check-sheet
[and place it in a sealed envelope with your initials signed over the
seal. Give the sealed envelope to the externship applicant to be
included in their application packet.]{.underline} Call your IHS
Preceptor at the IHS site if you have questions.

Student's Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Dental School \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Projected Graduation Date\_\_\_\_\_\_\_\_

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Name of Reference\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Title\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Amount of Time you have known this student \_\_\_\_\_\_\_\_\_\_Years
\_\_\_\_\_\_\_\_Months

Please rate the dental student using this scale: **A**-well exceeds
expectations, **B**-above average, **C**-average, **D**-below average,
**E**-consistently poor performance

**1. Please X the space that best corresponds to this student's
abilities**

  ----------------------------------------------- ------- ------- ------- ------- -------
                                                  **A**   **B**   **C**   **D**   **E**

  Quality of work and interest in improvement                                     

  Displays motivation                                                             

  Awareness of capabilities and limitations                                       

  Maintains calm and confident manner                                             

  Ability to interact with staff and patients                                     

  Responsiveness to criticism                                                     

  Capacity for development and learning                                           

  Shows genuine interest in helping people                                        

  Shows genuine interest in Public Health                                         
  Dentistry                                                                       

  Goes above and beyond the call of duty for                                      
  patients                                                                        
  ----------------------------------------------- ------- ------- ------- ------- -------

**2. Please circle to describe the student's capabilities in the
following areas:**

ORAL SURGERY (simple exodontias) Strong Fair Weak Unknown

ORAL SURGERY (surgical extractions) Strong Fair Weak Unknown

PEDIATRIC DENTISTRY (simple restorative) Strong Fair Weak Unknown

RESTORATIVE (Amalgams, Composites) Strong Fair Weak Unknown

DIAGNOSTIC ABILITIES Strong Fair Weak Unknown

ORAL MEDICINE/PATHOLOGY Strong Fair Weak Unknown

**3. Please use this space to provide any additional information
regarding the student's abilities from items 1 and 2 above:**

4\. **To the best of your knowledge, does this student exhibit a genuine
interest in working for the Indian Health Service after graduation?**
The Indian Health Service Externship provides students with an
experience of a lifetime, but it is also an important recruitment tool.

**Please check one.**

\_\_\_Highly likely. The student is very interested in a Public Health
career.

\_\_\_ Somewhat likely. The student may be more interested if the
externship goes well.

\_\_\_Not likely now but possibly in the future (Example: student has a
military commitment or may be interested in working for the Indian
Health Service after specialization)

\_\_\_Not likely at all. The student has other plans after graduation
(specialization, going into private practice).

5\. **To the best of your knowledge, does this student have any problems
interacting with Dental School staff including Dental Educators, fellow
Dental students, or Dental School Support Staff?** YES NO UNKNOWN

Please comment:

7\. **Does the student have adequate record-keeping skills including
legible handwriting?** YES NO UNKNOWN

8\. **Please feel free to attach any additional information you have on
this student or call if you would like to speak with me.** You can reach
me at the Indian Health Service -- Division of Oral Health at (301)
443-0029 or via email at <Timothy.Lozon@ihs.gov> if you have any
questions. Thank you very much for taking the time to fill out this
reference check-sheet.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Reference Signature Date