Milford Regional Medical Center - Professional Reference Survey

Question Title

* 1. Contact Information

Applicant Name

Your Name

Your Telephone Number

Question Title

* 2. Relationship

Your relationship to applicant

Your title

How long have you worked with the applicant?

Company name

Applicant's position held

Applicant's reason for leaving

Is the applicant eligible for rehire? If no, why not?

Question Title

* 3. Please indicate level of competence for the following. If you answer Fair or Poor, please elaborate in "Areas for Development" below.

	Excellent	Good	Fair	Poor
Customer service skills	Customer service skills Excellent	Customer service skills Good	Customer service skills Fair	Customer service skills Poor
Communication skills	Communication skills Excellent	Communication skills Good	Communication skills Fair	Communication skills Poor
Quality of work	Quality of work Excellent	Quality of work Good	Quality of work Fair	Quality of work Poor
Taking responsibility for own actions	Taking responsibility for own actions Excellent	Taking responsibility for own actions Good	Taking responsibility for own actions Fair	Taking responsibility for own actions Poor
Decision-making skills	Decision-making skills Excellent	Decision-making skills Good	Decision-making skills Fair	Decision-making skills Poor
Flexibility in varying needs and situations	Flexibility in varying needs and situations Excellent	Flexibility in varying needs and situations Good	Flexibility in varying needs and situations Fair	Flexibility in varying needs and situations Poor
Positive use of constructive criticism	Positive use of constructive criticism Excellent	Positive use of constructive criticism Good	Positive use of constructive criticism Fair	Positive use of constructive criticism Poor
Ability to learn and apply new information	Ability to learn and apply new information Excellent	Ability to learn and apply new information Good	Ability to learn and apply new information Fair	Ability to learn and apply new information Poor
Attitude towards work	Attitude towards work Excellent	Attitude towards work Good	Attitude towards work Fair	Attitude towards work Poor
Ability to work independently	Ability to work independently Excellent	Ability to work independently Good	Ability to work independently Fair	Ability to work independently Poor
Asks questions and seeks help as appropriate	Asks questions and seeks help as appropriate Excellent	Asks questions and seeks help as appropriate Good	Asks questions and seeks help as appropriate Fair	Asks questions and seeks help as appropriate Poor
Initiative	Initiative Excellent	Initiative Good	Initiative Fair	Initiative Poor
Interaction with others: peers/management	Interaction with others: peers/management Excellent	Interaction with others: peers/management Good	Interaction with others: peers/management Fair	Interaction with others: peers/management Poor
Attendance/punctuality	Attendance/punctuality Excellent	Attendance/punctuality Good	Attendance/punctuality Fair	Attendance/punctuality Poor
Technical/computer skills	Technical/computer skills Excellent	Technical/computer skills Good	Technical/computer skills Fair	Technical/computer skills Poor
Clinical skills	Clinical skills Excellent	Clinical skills Good	Clinical skills Fair	Clinical skills Poor
Demonstrates teamwork and assists coworkers	Demonstrates teamwork and assists coworkers Excellent	Demonstrates teamwork and assists coworkers Good	Demonstrates teamwork and assists coworkers Fair	Demonstrates teamwork and assists coworkers Poor
Proficiency in area of specialization	Proficiency in area of specialization Excellent	Proficiency in area of specialization Good	Proficiency in area of specialization Fair	Proficiency in area of specialization Poor

Question Title

* 4. Additional information

Principal Strengths

Areas for Development

General Comments