Work History Verification Form

Work History Verification

The applicant named below has applied for a position with BEYNDCARE NURSING SERVICES has listed you for reference purpose. The applicant has authorized this request to verify employment and his/her performance. We would appreciate your assistance in verifying employment and evaluating job performance.

Applicant *

Date *

Position Held *

From *

To *

Reason for Leaving

1. Is the information in the applicant section accurate?

Yes

No

If no, please explain

2. Was the applicant ever disciplined for work related conduct or incidents?

Yes

No

If yes, please explain

3. Is the applicant eligible for re-hire?

Yes

No

If no, please explain

4. Were there issues related to this person’s departure that would cause concern (i.e. violence, threats of violence, dishonesty, theft)?

Yes

No

If yes, please explain

Please evaluate this applicant.

Poor

Below Average

Average

Above Average

Excellent

Quality of work

Poor

Below Average

Average

Above Average

Excellent

Productivity

Poor

Below Average

Average

Above Average

Excellent

Rapport with staff and patients

Poor

Below Average

Average

Above Average

Excellent

Adaptability to change

Poor

Below Average

Average

Above Average

Excellent

Ability to handle stress

Poor

Below Average

Average

Above Average

Excellent

Follows established procedures

Poor

Below Average

Average

Above Average

Excellent

Attendance/Punctuality

Poor

Below Average

Average

Above Average

Excellent

Professional Appearance

Poor

Below Average

Average

Above Average

Excellent

Attitude/Interest/Enthusiasm

Poor

Below Average

Average

Above Average

Excellent

Communication Skills

Poor

Below Average

Average

Above Average

Excellent

Dependability

Poor

Below Average

Average

Above Average

Excellent

Honesty

Poor

Below Average

Average

Above Average

Excellent

Additional Comments

Employer

Person Contacted

Position

Phone

Fax

Other