Expanded Function Dental Auxiliary Employer Reference Form

Expanded Function Dental Auxiliary Employer Reference Form

The purpose of this form is to assist the selection committee in selecting students applying for the EFDA program that show evidence of the skills necessary to become an EFDA in Ohio. This information is held in strict confidence and will be used solely for making decisions about admittance into the EFDA Program.
Name of Student:*

First NameLast Name
Student's Date of Birth:*

MonthDayYear
Date
Dental Office Name:*
Dental Office Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist/Dental Office Email*
example@example.com
Dental Office Phone Number*
Please enter a valid phone number.
Start date with dental practice*
End date:
*If employee is no longer working for you provide the last date of employment.
The following evaluation should be based on demonstrated performance compared to that reasonably expected of an auxiliary at their level of training, experience, and background.

4=Excellent 3=Good 2=Fair 1=Poor or Not Observed, if applicable
Basic Professional Knowledge*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Judgment*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Professional Manner and Appearance*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Technical/Hand Skills*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Following Directions*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Cooperativeness*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Punctuality/Dependability*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Communication Skills*

1 (Poor)2 (Fair)3 (Good)4 (Excellent)Not Observed
Dentist Name:*

First NameLast Name
Dentist Signature*

Clear
Should be Empty: