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: