Reference Check
Your Name
First Name
Last Name
Candidate Name (Person reference is for)
First Name
Last Name
Your Phone Number
Format: (000) 000-0000.
Name of Company/Hospital Facility
Position Candidate Held
Your Title at above Company
Approximate Date of Candidate's Employment (If known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Questions and Details:
What was your relationship with the applicant?
Please briefly describe the applicant’s responsibilities.
Please rate the Candidate’s effectiveness in the areas of:
Rows
Very Satisfied
Satisfied
Somewhat Satisfied
Not Satisfied
Work Ethics
1
2
3
4
Relationship with peers/managers
5
6
7
8
Attendance
9
10
11
12
Overall Performance
13
14
15
16
Strengths:
Areas of needed development:
Reason Candidate Left Position:
Would you recommend this applicant for hire or re-hire?
Please Select
Yes
No
Submit
Should be Empty: