Candidate's Name

Reference's Name

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 PoorPoorAverageGoodVery Good

PROFESSIONAL JUDGEMENT
Very PoorPoorAverageGoodVery Good

ORGANIZATIONAL SKILLS
Very PoorPoorAverageGoodVery Good

ETHICAL CONDUCT
Very PoorPoorAverageGoodVery Good

ABILITY TO WORK WITH OTHERS
Very PoorPoorAverageGoodVery Good

COMPETENCE AND SKILL LEVEL
Very PoorPoorAverageGoodVery Good

VERBAL COMMUNICATION SKILLS
Very PoorPoorAverageGoodVery Good

WRITTEN COMMUNICATION SKILLS
Very PoorPoorAverageGoodVery Good

PATIENT SATISFACTION
Very PoorPoorAverageGoodVery Good

Recommendation
Recommend highly without reservationRecommend as qualified and competentRecommend with some reservationDo not recommend

Do you think this candidate would be a good fit to work at an FQHC?
YesNo

Is there anything we should know that I have not asked you or do you have additional comments to share regarding this person?