New Reference Form New Refrence Form CANDIDATE NAME* First FACILITY INFORMATION Facility Name* City/State Reference Name Position(s) Held Travel Assignment Employment Dates Average Patient Ratio No Of Beds in FacilityWould you rehire? PERFORMANCE AND ATTRIBUTES Experience scale: 1 – N/A /2 – Below Standard /3 – Meets Standard /4 - Above StandardProvides competent clinical care following facility policies and procedures 1 2 3 4 Completes accurate documentation of patient care 1 2 3 4 Communicates effectively w/ patients, families and staff 1 2 3 4 Flexibility and adaptability 1 2 3 4 Overall professionalism 1 2 3 4 ADDITIONAL COMMENTS Reference Completed By: Evaluation Date: MM slash DD slash YYYY
