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Clinic Volunteer Reference Form

This document is a reference check form for a potential volunteer. It requests that the reference complete questions rating the individual's work quality, dependability, interactions, leadership, and involvement with others. It asks how long the reference has known the individual and the nature of their relationship. The form must be returned in a sealed envelope with the reference's signature across the seal within one week.

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Anonymous 9XRW2znu
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12 views

Clinic Volunteer Reference Form

This document is a reference check form for a potential volunteer. It requests that the reference complete questions rating the individual's work quality, dependability, interactions, leadership, and involvement with others. It asks how long the reference has known the individual and the nature of their relationship. The form must be returned in a sealed envelope with the reference's signature across the seal within one week.

Uploaded by

Anonymous 9XRW2znu
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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DearSirorMadam:

Thankyouforagreeingtobeareferenceforourvolunteer.Pleasecompletethisentireform.Our
volunteersmusthaveatleasttwowrittenreferencesonfilebeforetheycanprovideservicewithour
organization.Yourreferencecheckformmustbereturnedtothepotentialvolunteer,attn:Volunteer
Coordinator,inasealed(unopened)envelopewithyoursignaturewrittenacrosstheseal.Your
response(within1weekuponreceiptofthisform)isgreatlyappreciated.
PotentialVolunteersName:___________________________________________________________
ReferenceName:_________________________________________Title:_______________________
Organization:_______________________________________________________________________
Address:___________________________________________________________________________
City:________________________________State:______________________Zip:_______________
Phone:___________________Fax:____________________Email:___________________________
Pleasecheckonecolumnperquestion:

Questions

Unsatisfactory Satisfactory Excellent

Howwouldyourankthisindividual'squalityof
work?
Howwouldyourankthisindividual's
dependability?
Whatis/wasthisindividualliketointeractwithasa
coworker,employee,associate,orstudent?

Howis/wasthisindividual'sinvolvementwith
clients/patients/customers/others?

Howwouldyourankthisindividual'sleadership
capabilities?

Howlonghaveyouknowthisindividual?________________________________________________
Whatisyourrelationshiptothisindividual?_______________________________________________
Inordertoensurethehighestpossiblequalityofcareforourpatients,pleasebrieflydescribeanyareas
ofconcernthatweshouldknowaboutregardingthisindividual._______________________________
__________________________________________________________________________________
Wouldyourecommendthisindividualforavolunteerpositionwithourorganization?_____________
Additionalcommentscanbewrittenontheback.
ReferencesSignature:_____________________________________Date:_______________________

7/8/2011

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