Travel Nurse Reference Form
Candidate Information
Name
First Name
Last Name
Position Applied For
Email
example@example.com
Phone Number
Please enter a valid phone number.
Reference Provider Information
Name
First Name
Last Name
Position/Title
Organization/Company Name (if applicable)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to the Candidate
Supervisor
Colleague
Other
Please briefly explain the length of time you have known the candidate & in what capacity have you worked with the candidate?
Professional Competencies
Please rate the candidate on the following competencies using a scale of 1 to 5 (1 being the lowest and 5 being the highest)
Adaptability
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Clinical Skills
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Communication
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Team Collaboration
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Problem-Solving
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Reliability
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Flexibility
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Cultural Competence
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Leadership
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Provide specific examples or anecdotes that illustrate the candidate's strengths and areas of improvement related to the competencies mentioned above.
Would you recommend the candidate for a travel nursing position?
Yes
No
Additional Comments
Submit
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