Candidate Information

Candidate Name:      

Employment Dates:       /       -       /      

Position/Job Title:      

Salary/Pay Rate: $       Per      

Job Responsibilities:      

Reference Information (Please enter the following information for the person completing this verification.)

Name:      

Title:      

Telephone No.:      

How are you acquainted with the candidate named above? Supervisory role Co-worker Other:      

Signature: Date:

Reference Questions

How are you acquainted with the candidate?

Supervisory role (Verify dates of candidate’s previous employment.)

Coworker

Other (e.g., minister, doctor, teacher, lawyer)

Note: Friends are not acceptable references. The candidate must have worked with the reference or must know the reference on a professional basis.

When did you work with the candidate?      

What were the candidate’s main job duties and responsibilities?      

Why did the candidate leave your organization?      

Were there any attendance problems? Yes No

If Yes, please explain:      

Reference Questions (cont’d.)

Have you had the chance to watch the candidate interact with children? Yes No

If Yes, were the interactions positive? Yes No

Why or why not?      

Do you believe the candidate would be suitable to work at a school, in direct contact with children?

Yes No

Why or why not?      

Would you have any reservations about the candidate in such a position? Yes No

If Yes, please explain:      

What other comments would you like to add regarding the candidate?      

Performance Assessment (On a scale of 1 to 5, please rate the following aspects of the candidate’s performance.)

1 - Poor 2 - Below Average 3 - Average 4 - Above Average 5 - Excellent N/A - Not applicable

Task

1

2

3

4

5

N/A

Accepted and grew from professional criticism

Acted as an effective role model

Communicated verbally

Exhibited high expectations for self and others

Maintained accurate records

Solved problems

Worked with other staff

Worked with supervisors

Communicated with parents

Controlled and maintained discipline in a classroom

Got involved in extra-curricular activities

Used multiple teaching strategies

Worked with children

Overall rating of the candidate

If you could rehire this person, would you do so? Yes With Reservation No

If No or With Reservation, please explain: