(Please add the CANDIDATE'S Full Name in the box after "Reference for")

Date

Your Name

Title

Facility

Location

Telephone

Email Address

Relationship

Years Known

If any of the following questions are not applicable, insert "NA"

Leadership/Management Style/Skills:


Clinical Skills or Knowledge Base:


Communication and Interpersonal Skills (written & verbal; with superiors, subordinates, peers)


Physician Relationships:


Staff Relationships:


Key Strengths:


Areas for Development:


Personal Problems Interfering with Performance/Attendance:


Reason for Leaving:


Would You Employ if You Had a Suitable Position:


Professional Appearance and Demeanor:


Additional Comments (that would help us form an accurate assessment of the candidate)