Healthcare Reference Form Candidate Name(Required) First Last Reference Name(Required) First Last Reference Title (Charge RN, Nurse Supervisor, Manager, Etc.)(Required)Reference Phone Number(Required)Reference Email(Required) Hospital/Facility(Required)Facility Address (Including City/State/Zip)(Required)Did you have direct supervision over this candidate?(Required) Yes No Average Hours Per Week Candidate Worked(Required)Start Date (MM/YYYY)(Required) Month If unknown, type 01 Year End Date (MM/YYYY)(Required) Month If unknown, type 01 Year Is this individual currently employed at this facility/hospital?(Required) Yes No Employee's Job Title (E.G.: RN, EEG Tech, CNA, Phlebotomist, etc.)(Required)What is the primary unit/specialty this individual worked on?(Required)Type of Patients (Example: Cardio, Ortho, Peds vs. Adults)(Required)# of Beds on the Unit(Required)Performance/AttributesPlease rate this individual on a scale of "Exceeds Expectations, Meets Expectations, or Does Not Meet Expectations" based on your experience working with them. Please select only one option per category.Patient Assessment(Required)Assesses patients in a timely, thorough and individualized manner according to patient need. Exceeds Expectations Meets Expectations Does Not Meet Expectations Teamwork/Collaboration(Required)Works collaboratively with other members of the team to develop an individualized plan of patient care. Exceeds Expectations Meets Expectations Does Not Meet Expectations Clinical/Technical Competency(Required)Performs interventions in a timely, accurate and safe manner. Exceeds Expectations Meets Expectations Does Not Meet Expectations Accurate Documentation(Required)Documents the patient care process accurately. Exceeds Expectations Meets Expectations Does Not Meet Expectations Age Specific Competency(Required)Demonstrates competency appropriate for assigned patient population including adaptations for age specific care. Exceeds Expectations Meets Expectations Does Not Meet Expectations Communication Skills(Required)Communicates respectfully and effectively with patients, families, visitors and all facility staff and physicians. Exceeds Expectations Meets Expectations Does Not Meet Expectations Adherence to Policies and Procedures(Required)Adheres to facility policies and procedures. Exceeds Expectations Meets Expectations Does Not Meet Expectations Reliability/Attendance(Required)Reports to work on time as scheduled. Notifies immediate supervisor if unable to work. Exceeds Expectations Meets Expectations Does Not Meet Expectations Professionalism(Required)Exhibits a high level of professionalism. Exceeds Expectations Meets Expectations Does Not Meet Expectations Flexibility/Adaptability(Required)Exhibits flexibility and adaptability. Exceeds Expectations Meets Expectations Does Not Meet Expectations Reason for leaving this position(Required)Are they eligible for rehire?(Required) Yes No Additional CommentsConsent(Required)By checking this box, you agree that Level One Personnel may use your reference to consider this candidate's eligibility for employment. You also understand that we may contact you regarding this reference and the information provided. I confirm that all information provided on this reference is true and accurate to the best of my ability
