Form PHS-1813 at a glance
What it is: This is the Reference Request for Applicants to the Commissioned Corps of the U.S. Public Health Service.
Who signs: The reference, not the applicant, signs in 8. SIGNATURE. The reference answers the questions to help determine whether this person is loyal, trustworthy, and of good character, and the information the reference provides will be disclosed to the applicant if he or she should so request.
A filled-in Form PHS-1813 example: a former supervisor completes the back of the form
How to fill out Form PHS-1813, box by box
Applicant's name and other names
To be completed by the applicant: Applicant's Name (Last, First, Middle Initial).
If the reference knows the applicant by any other name, e.g., maiden name, indicate that name here. Enter only other names the applicant has used.
Period of association
In 1. PERIOD OF ASSOCIATION, enter From and To as (MM/YYYY).
Professional relationship to applicant
For 2. PROFESSIONAL RELATIONSHIP TO APPLICANT, check the appropriate boxes: Employer, Teacher, Faculty Advisor, Supervisor, Dean or Other (specify).
Evaluation of applicant
For 3. EVALUATION OF APPLICANT, provide any details in section 7.
In section 3, for each of the ELEMENTS, mark one: Outstanding, Better than Average, Average, Below Average or No Basis for Judgment.
The ELEMENTS are Productivity, Ability to Work With and For Others, Ability to Work Independently, Flexibility -- Adaptability, Initiative, Ability to Solve Problems -- Resourcefulness, Application of Skills and Knowledge, Capacity for Development, Originality, Attendance, Judgment, Dependability in Carrying Out Assignments, Ability to Communicate (Oral/Written) and Supervisory Ability.
Best suited specialization, field, or position
For 4., enter the specialization, field, or position the applicant is best suited for.
Limitations or other information
For 5., do you know of any limitations or other information which might impact on the effectiveness or stability of this person (Training, Personality, Emotional, Ethical)? Mark NO or YES (Give Details in this Space).
Willing to employ or re-employ this person
For 6., would you be willing to employ or re-employ this person if you had an opening requiring the general professional level and profession of this individual? Mark YES (IN WHAT CAPACITY?) or NO (GIVE REASONS).
Comments
In 7. COMMENTS, use the space to supply any further information, comments from section 3 and/or evaluation.
Signature, name, title, date and address
Sign in 8. SIGNATURE.
Type or print your name in 9. NAME, then enter 10. TITLE OR POSITION and 11. DATE.
In 12. INSTITUTION OR FIRM ADDRESS, include the ZIP Code and do not attach business cards.
Enter the Telephone No. and Ext.
More rules for Form PHS-1813
Your name has been given as a reference by the individual who has applied for appointment to the Commissioned Corps of the United States Public Health Service. To help the Office of Commissioned Corps Operations determine whether this person is loyal, trustworthy, and of good character, answer all questions on the front and back of this form as fully and specifically as you can. The information you provide will be disclosed to the person identified in Applicant's Name if he or she should so request.
Sources
[1] Form PHS-1813 (Rev. 8/10), Reference Request for Applicants to the Commissioned Corps of the U.S. Public Health Service, U.S. Department of Health and Human Services (the Official source link on this page).