Character Reference

Character Reference Form
This form is intended to collect a personal character reference for an individual
applying for a role in home care. Your honest and thoughtful feedback will help
ensure we select the most compassionate, responsible, and trustworthy caregivers.
Applicants' Details
Full Name of Applicant*

First NameLast Name
Referee Information
Full name of Referee*

First NameLast Name
Your occupation (optional)
What is your relationship to Applicant?*
How long have you known the Applicant?*

Less than a year1-3 years3-5 years5+ years
Applicant's Character Reference
Please evaluate the applicant by selecting the rating that best describes your
experience with them.
Punctuality and Dependability*

SatisfactoryGoodExcellent
Honesty and Trustworthiness*

SatisfactoryGoodExcellent
Compassion and Empathy*

SatisfactoryGoodExcellent
Communication Skills*

SatisfactoryGoodExcellent
Teamwork and Cooperation*

SatisfactoryGoodExcellent
Initiative and Independence*

SatisfactoryGoodExcellent
Emotional Stability and Stress Management*

SatisfactoryGoodExcellent
Suitability for a Home Care Role*

SatisfactoryGoodExcellent
Additional Comments (Optional)
Please share any additional observations or specific examples that reflect the applicant’s character and readiness for a home care position:
Signature (optional)
Date

MonthDayYear
Date
Should be Empty:

Character Reference Form