Reference Check Form
Provide professional references for employment verification.
Applicant Name
*
First Name
Last Name
Position Applied For
*
Please Select
Caregiver
Direct Care Worker
Other
Date of Reference Check
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reference Name
*
First Name
Last Name
Company/Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Verified By
*
How do you know the applicant?
*
Dates of Employment (if applicable): From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dates of Employment (if applicable): To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Position Held
Would you describe the applicant as reliable?
*
Yes
No
Not Sure
Comments on reliability
Was the applicant punctual and dependable?
*
Yes
No
Not Sure
Comments on punctuality and dependability
How did the applicant interact with clients, coworkers, and supervisors?
*
Would you rehire this individual?
*
Yes
No
Not Sure
Comments on rehire
Any concerns regarding working with vulnerable adults or seniors?
Overall Recommendation
*
Highly Recommend
Recommend
Recommend with Reservations
Do Not Recommend
Staff Completing Reference Check - Name
*
First Name
Last Name
Staff Title
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: