Reference Form - StaffStack

Date Completed

Reference Form

Reference

Name

Title

Phone

Applicant

Applicant Name

Facility Worked at with Applicant

Applicant's Position

Employment Start Date

Employment End Date

Eligible for Rehire: Yes No

Rating Summary

1 Poor 2 Below Average 3 Average 4 Good 5 Excellent

Attendance / Reliability

Job Performance

Clinical Skills

Ability to Handle Difficult Situations

Works Well With Others

Patient Care / Safety Awareness

Strengths / Areas for Improvement / Additional Comments

By completing this form, the reference confirms that the information provided is accurate to the best of their knowledge and based on their direct professional experience with the applicant.

Healthcare Reference Form