Nurse Reference Check Form

Candidate Information

Candidate Name Position Applied For Reference Name Reference Position/Title Reference Facility/Organization Reference Phone/Email Relationship to Candidate Dates Worked Together

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Assessment

How long have you known or worked with the candidate? What was the candidate's primary role or duties? Reliability and Punctuality Excellent Good Average Poor Clinical Competence Excellent Good Average Poor Communication Skills Excellent Good Average Poor Ability to Work in a Team Excellent Good Average Poor Strengths Observed Areas for Improvement Would you recommend this nurse for employment? Yes No With Reservations Additional Comments

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Completed By

Name Date