Healthcare Worker Reference Check Form
Candidate Information
Full Name
Position Applied For
Workplace/Department
Reference Information
Reference Name
Relationship to Candidate
Contact Information
Organization
Employment Details
Dates of Employment
Position/Role and Main Duties
Work Performance Assessment
Reliability/Punctuality
Skills and Competency
Attitude/Professionalism
Ability to Work in a Team
Communication Skills
Patient Care/Client Interaction
General Comments
Strengths
Areas for Improvement
Would you rehire this candidate?
Yes
No
Unsure
Additional Comments
Reference Signature
Signature
Date