PROFESSIONAL REFERENCE CHECK

 

Nurse:  Complete section below

I authorize Facility Representative                                                                                     (HR, Nurse Manager or Nurse Director, etc.) From:                                                                                                                                                                                            (Facility Name) Address:                                                                                                                                                                                   (Facility Address) Print Name:                                                                                                              Social Security #:                                                                 Applicant Signature:                                                                                                        Date:

 

Facility Representative:  Complete section below

 

PERFORMANCE EVALUATION

 

The above named nurse has applied for a nursing position with Critical Nursing Solutions, Inc. and has given us your name as

a clinical / professional reference.  We would appreciate it if you would evaluate the applicant’s past performance and make any

additional comments you might feel might assist us in making our decision in hiring this nurse.  Your comments will be kept in

strict confidence.

 

Name and Title of Reference:                                                                                                                                                                                   

Facility Name:                                                                                                                          Phone Number:                                                        

Address:                                                                                                    City, State, Zip:                                                                                          

Nurse employed:  From:                            To:                            Nurse’s Title:                                          Area(s) Worked:                                

(If multiple titles were held, please indicate below and utilize comment section)

Nurse employed:  From:                            To:                            Nurse’s Title(s):                                     Area(s) Worked:                                

Nurse employed:  From:                            To:                            Nurse’s Title(s):                                     Area(s) Worked:                                

 

	Exceeds Expectations	Meets Most Expectations	Meets Some Expectations	Does Not Meet Expectations
Quality of Work
Productivity
Professionalism
Emotional Stability
Flexibility
Dependability
Enthusiasm Toward Job
Leadership Ability
Communications Skills
Attendance/Punctuality
Appearance
Customer Service Skills

 

Reason this nurse left your facility:     Terminated __     Lay-off __    Resigned __   Temporary __    N/A __    Current Employee __  

 

Comments: (please continue on a separate page, if necessary)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 _________________________________

Would you hire this nurse again?            Yes __            No __

Signature                                                                                                                              Date                                                                       ____

 

Please return this form to:  FAX # 480-452-0308                                 CRITICAL NURSING SOLUTIONS, INC.                                 625 North Gilbert Road, Suite 204                                 Gilbert, AZ  85234

INTERNAL USE ONLY Person verifying reference:                                          _________                  Verbal                       Written        Date: