Reference Check Form

Candidate Name:*

Email:

Phone:

Position/Job applying for:

Facility Name:

Facility full Address:

Dates Worked:

Reason for leaving:

Professional Reference: (To Be Filled By Performance/reference Provider)

Quality of Work*

Interpersonal Skills*

Job Knowledge*

Interest & Enthusiasm*

Communicates well with patients/Families and Staff*

Flexibility & Adaptability*

Attendance & Punctuality*

Ability to Handle Stress*

Ability to take charge*

Overall Professionalism*

To Be Filled By Reference Provider

Is applicant eligible for rehire?*

YesNo

Are there any noteworthy strengths you’d like to mention?

Reference Provider Name:*

Title/Designation (Reference Provider):

Phone:

Email:

Date of reference check done:

IMPORTANT: The verifier should accomplish this part otherwise this document is not valid.

Reference Check Done by (Full Name):

Reference Check Done by (Tittle/Position):