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Reference Form
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Your Name
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Email
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State
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What is your current occupation?
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Applicant Name
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Briefly describe your relationship with the applicant
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Could you verify that the applicant worked as a technician?
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Yes
No
How comfortable is the applicant at restraining patients?
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A
B
C
Please rate the applicant from A-C (A being comfortable, B being somewhat, C being not able)
How would you rate this person's attendance and dependability?
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A
B
C
Please rate the applicant from A-C (A being comfortable, B being somewhat, C being not able)
How comfortable is the applicant at drawing blood?
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A
B
C
Please rate the applicant from A-C (A being comfortable, B being somewhat, C being not able)
How comfortable is the applicant at doing IV placements?
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A
B
C
Please rate the applicant from A-C (A being comfortable, B being somewhat, C being not able)
How comfortable is the applicant at administering vaccines?
*
A
B
C
Please rate the applicant from A-C (A being comfortable, B being somewhat, C being not able)
How comfortable is the applicant assisting in surgery?
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A
B
C
Please rate the applicant from A-C (A being comfortable, B being somewhat, C being not able)
Please verify which equipment the applicant is comfortable operating.
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What are the dates of employment for the applicant?
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Is the applicant eligible for rehire?
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Yes
No
Is there anything else that you would like to say about the applicant?
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