Reference

Birth Date

Date

Candidate's Name whom this reference is for:(Required)

First Name Last Name

What was their position or title?

Company/Organization's Name:

City and State:

Date Employment Started:

Start date: Month/Year

Date Employment Ended:

End date: Month/Year

Reason for leaving?

Would you rehire this individual?

Yes

Not Sure

Your Full Name Please(Required)

First Name Last Name

Your Phone Number:

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Your relationship to candidate:

Supervisor

Co-worker

Academic

Other

Clinical Assessment

Attendance

Shows up on time every time

Clinical Performance

Candidates ability to make clear sound and proactive decisions reflecting good clinical skills/judgment

Patient and Customer Focused

Demonstration of customer/people service/patient care

Teamwork and Collaboration

Shows respect for the contribution of others, communicates with patient, family, and team members clearly and concisely.

Effective Communication

Articulate, can relate to all levels/listen & handle difficult people/conflict

Planning and Organization

Ability to assess, plan and prioritize care for more than one patient

Documentation

Records all aspects of patient status accurately and timely

Professional Assessment

Trustworthiness

Dependability

Shows initiative

Work Habits

Flexibility

Follows procedures well

Reliability

Fast Learner

Please add any extra details or testimonies about candidate:

Reference

Reference

Clinical Assessment

Professional Assessment

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