TE_3-_Attch_6._Reference_Form_Example_DEROG_ONLY.pdf

YES NO

INSUFFICIENT

OPPORTUNITY

TO OBSERVE

AVERAGE

UNSATIS-

FACTORY

7. DATE (DDMMMYYYY)

REMARKS

8. PRINTED NAME and POSITION TITLE 9. SIGNATURE

5e. JOB KNOWLEDGE-Has knowledge of techniques and procedures applicable to the job for which being considered.

FOR SUPERVISORY POSITIONS ONLY

6a. MANAGERIAL SKILLS-Ability to plan and organize work.

6b. SUPERVISION-Ability to supervise other employees.

5b. COOPERATION & CONSIDERATION FOR OTHERS-A team player, maintains good relationships, consistently demonstrates consideration.

5c. SOUND JUDGMENT-Makes informed decisions.

5d. ADAPTABILITY-Ability to adjust to changes in working or living environments.

3. Would you reemploy applicant in the same position? (If no, explain below in Remarks)

4. Do you have any knowledge of any behavior, activities, or associations which tend to show that this person is not honest, trustworthy, and of good conduct and character? (If yes, explain below in Remarks)

PERSONAL APPRAISAL ABOVE AVERAGE

5a. DEPENDABILITY-Accepts assigned responsibility and effectively accomplishes duties in approved manner within time established.

CHECK APPLICABLE BOX

CHILD CARE SERVICES REFERENCE CHECK FORM

APPLICANT NAME: 1. HOW LONG HAVE YOU KNOWN THE APPLICANT AND IN WHAT

CAPACITY? (Check applicable block)

CAPACITY TIME KNOWN

REFERENCE NAME: SUPERVISOR

EMPLOYER

REFERENCE ORGANIZATION: OTHER (specify)

2. IFA SUPERVISOR REFERENCE, AND THE INDIVIDUAL IS NO

LONGER EMPLOYED, PROVIDE REASON FOR LEAVING:

CONTACT INFORMATION:

Reference