Reference Check – Grant Nov 09, 2017 If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Candidate's Name * Reference's Name * Title Phone Email * How long have you known this candidate? * What is your relationship with this candidate? What notable strengths does he/she possess? * What would you say are the candidate’s weaknesses? * What concerns do you have that you think might compromise his/her job performance? How would you rate the amount of work he/she accomplished? Please evaluate the candidate in the following areas according to this scale: (leave blank if not observed) LEVEL OF COMMITMENT PROFESSIONAL JUDGEMENT SENSE OF RESPONSIBILITY ORGANIZATIONAL SKILLS ETHICAL CONDUCT ABILITY TO WORK WITH OTHERS COMPETENCE AND SKILL LEVEL VERBAL COMMUNICATION SKILLS WRITTEN COMMUNICATION SKILLS PATIENT SATISFACTION Recommendation: * Recommend highly without reservation Recommend as qualified and competent Recommend with some reservation Do not recommend Do you think this candidate would be a good fit to work at an FQHC? * Yes No Is there anything we should know that I have not asked you or do you have additional comments to share regarding this person?