Employment References Date* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM Your Name:* Employee's Name:* What company did you have working experience?* Your Email:* Your Phone (in case we have additonal questions):*How do you know this person?*Current SupervisorCurrent Co-workerFormer SupervisorFormer Co-workerFriendRelativeWhen did you work with this person?* What were his/her job duties?* Did this person perform these duties competently?*YesNoHow was this person's attendance record?* If this person missed much work, what were the major reasons (i.e. illness, family issues; etc.)? Is this person punctual? Is this person dependable? Is this person honest/trustworthy? Is this person tactful? Does this person use good judgement? Is this person compassionate? Does this person show initiative? Is this person a "Team Player"? Does this person respect authority? Does this person need constant supervision? Can this person perform under pressure? Have you ever had any disciplinary issues with this person?* What do you feel this person's main strengths are? What do you feel this person's weaknesses are? This person has applied for a pediatric private duty nursing position, do you feel this person is suitable for it?* What was the reason this person left your employment?* Would you hire or work with this person in the future?* Do you have any other comments you would like to make?* CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.