CENTRAL REGION RESPITE SOCIETY
REFERENCE CHECK	Date: ________________
Applicant: _____________________________________________________________________ Reference: _________________________________________  Phone: ____________________ Reference's Agency/ Organization: _________________________________________________ How well do you know the applicant? _______________________________________________ Assessment of Interpersonal Skills {Communication Skills; Confidence; Decision Making Skills / Judgment; Maturity / Self Awareness; Sense of Humor; Creativity} _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Assessment of Professional Skills {Reliability / Commitment; Initiative / Independence; Roles and Responsibilities; Problem Solving Skills} _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Would you allow them to care for your child or family member?      YES   NO If the situation arose, would you re-hire them?      YES   NO Additional Comments: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Not Recommend      Recommend      Highly Recommend

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