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Reference Check Form
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Volunteer/Student Reference Check (CONFIDENTIAL)
Dear Referee: Given the sensitive and confidential nature of the work that we do at Bissell Centre, it is imperative that all candidates interested in volunteering or completing their practicum here are screened through a process that includes verifiable reference checks. As such, we ask that you please take a few minutes of your time to complete this form. Please be sure to include any additional comments that you believe would be of benefit to us determining a candidate's suitability. Thank you.
Applicant
Please provide the full name of the applicant for whom you are providing this reference.
Name
*
First
Last
Relationship
What is the nature of your relationship to the applicant?
*
Personal
Business
Academic
How well would you say you know the applicant?
*
Well Known
Moderately Known
Somewhat Known
How long have you know the applicant in months/years?
*
Personality
Please check each item at the point of scale which best indicate your rating of this individual.
Maturity
*
Excellent
Good
Average
Fair
Poor
Unknown
Reliability
*
Excellent
Good
Average
Fair
Poor
Unknown
Professionalism
*
Excellent
Good
Average
Fair
Poor
Unknown
Personality
Please check each item at the point of scale which best indicate your rating of this individual.
Integrity
*
Excellent
Good
Average
Fair
Poor
Unknown
Communication Skills
*
Excellent
Good
Average
Fair
Poor
Unknown
Interpersonal Skills
*
Excellent
Good
Average
Fair
Poor
Unknown
Personality
Please check each item at the point of scale which best indicate your rating of this individual.
Cultural Sensitivity
*
Excellent
Good
Average
Fair
Poor
Unknown
Empathy
*
Excellent
Good
Average
Fair
Poor
Unknown
Team Player
*
Excellent
Good
Average
Fair
Poor
Unknown
Personality
Please check each item at the point of scale which best indicate your rating of this individual.
Ability to remain composed during stressful situations
*
Excellent
Good
Average
Fair
Poor
Unknown
Adherence to guidelines/procedures
*
Excellent
Good
Average
Fair
Poor
Unknown
Do you have any concerns, questions, or reservations with regard to the applicant as a volunteer or completing their practicum at Bissell Centre?
If you are/were in a capacity to hire this individual to work with you, would you do so?
Is there anything else you would like to share with regard to the applicant?
*
Referee Information
Please fill out this section with your information
Name
*
First
Last
Occupation
Email
*
Phone
Date
*
MM slash DD slash YYYY