Reference Check – Billing

Candidate's Name*

First

Last
Reference's Name*

First

Last
Reference Job title
Reference Email
How long have you known this candidate?*
What is your relationship with this candidate?
What notable strengths does the candidate possesses?*
What would you say are the candidate’s weaknesses?*
What concerns do you have that you think might compromise the candidate's 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
- Very Poor
- Poor
- Average
- Good
- Very Good
PROFESSIONAL JUDGEMENT
- Very Poor
- Poor
- Average
- Good
- Very Good
PROFESSIONAL JUDGEMENT
- Very Poor
- Poor
- Average
- Good
- Very Good
ORGANIZATIONAL SKILLS
- Very Poor
- Poor
- Average
- Good
- Very Good
ETHICAL CONDUCT
- Very Poor
- Poor
- Average
- Good
- Very Good
ABILITY TO WORK WITH OTHERS
- Very Poor
- Poor
- Average
- Good
- Very Good
COMPETENCE AND SKILL LEVEL
- Very Poor
- Poor
- Average
- Good
- Very Good
VERBAL COMMUNICATION SKILLS
- Very Poor
- Poor
- Average
- Good
- Very Good
WRITTEN COMMUNICATION SKILLS
- Very Poor
- Poor
- Average
- Good
- Very Good
PATIENT SATISFACTION
- Very Poor
- Poor
- Average
- Good
- Very Good
Recommendation:*
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?