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Employment Reference Check #1

• Clinical references must provide dates of employment, give a rating of work history, state the position or specialty that the candidate worked. State the title of the person giving the references such as Charge RN, RN Supervisor, DON, Nurse Manager. The reference MUST be someone who the candidate reported to directly on the floor unit. •
Applicant’s Name
Address
Supervisor’s Name
Untitled
MM slash DD slash YYYY

Employment History

The person above is applying for an employment with Agency Staffing and has listed you as previous employer. We would appreciate your assistance in verifying employment and evaluating job performance. All information will be treated with utmost confidentiality.
Is this employee eligible for rehire?
Personal Evaluation
1. Clinical Competency
2. Quality of Work
3. Quantity of Work
4. Attitude and Cooperation
5. Ability to get along with others
6. Adaptability to Work Situations
7. Dependability
8. Attendance and Punctuality
9. Personal Appearance

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