5. DDD Reference Request Form

Reference Request

AZ Department of Economic Security | Division of Developmental Disabilities | Home and Community Based Services
APPLICANT

This reference request should be provided to a person who has personal knowledge about your employment history, educationor character and can attest to your ability to provide services. Two references should be from former/current employers. References CANNOT be from family members. Please fill in your name below and give to the person you are requesting a reference from. Instruct the person to mail this Reference Request back to the Division of Developmental Disabilities (DDD).
Applicant's Name*
Last, First, M.I.
Applicant's Address*
No., Street, City, State, ZIP
Applicant's Phone Number*
Please enter a valid phone number.
PERSON PROVIDING REFERENCE

Please complete the questions listed below keeping in mind that Home and Community Based Services (HCBS) may be performed unsupervised in the home of the person with developmental disabilities or in the residence/facility of the applicant. Your time and effort in completing this form is appreciated and strict confidentiality in regard to your responses will be observed within the provisions of the law.

This reference request MUST be returned to the HCBS local office listed on the reverse. If mailing, fold this form in half with the DES/DDD address on the outside, seal lower edge (NO STAPLES), attach stamp and mail.
Printed Name of Person Providing Reference*
Last, First, M.I.
Address of Person Providing Reference*
No., Street, City, State, ZIP
Phone Number*
Please enter a valid phone number.

State the Length of Time You Have Known the Applicant*

Rows	NUMBER OF
YEARS
MONTHS

Type of Acquaintance (Check all that apply)*

Supervised ApplicantWorked with ApplicantFriendNeighborOther
Indicate your feelings on how you believe the applicant will relate to individuals with developmental disabilities. Describe your knowledge of any characteristics and/or special training/education that the applicant may have for working with these individuals:*
Indicate if you have any reason to believe that the applicant would not be suited to provide services to individuals with developmental disabilities:*
If the applicant was a former employee, would you rehire this person?*

YesNoN/A
If no, why not?*
Additional comments which will help in evaluating this applicant:*
Signature of Person Providing Reference*
Date*

MonthDayYear
Should be Empty: