New Form

Caregiver Candidate Name

Position Applied For

Date of Reference Check

Reference Name

Company / Agency Name

Phone Number

Email Address

Dates of Employment

Did this individual work for you as a caregiver or personal care attendant?

Professional Performance Ratings (1 = Poor | 5 = Excellent)

	1	2	3	4	5
Quality of care provided	1Quality of care provided 1	2Quality of care provided 2	3Quality of care provided 3	4Quality of care provided 4	5Quality of care provided 5
Reliability and attendance	1Reliability and attendance 1	2Reliability and attendance 2	3Reliability and attendance 3	4Reliability and attendance 4	5Reliability and attendance 5
Ability to follow care plans and instructions	1Ability to follow care plans and instructions 1	2Ability to follow care plans and instructions 2	3Ability to follow care plans and instructions 3	4Ability to follow care plans and instructions 4	5Ability to follow care plans and instructions 5
Communication with clients and families	1Communication with clients and families 1	2Communication with clients and families 2	3Communication with clients and families 3	4Communication with clients and families 4	5Communication with clients and families 5
Professionalism and conduct	1Professionalism and conduct 1	2Professionalism and conduct 2	3Professionalism and conduct 3	4Professionalism and conduct 4	5Professionalism and conduct 5
Compassion, patience, and respect for clients	1Compassion, patience, and respect for clients 1	2Compassion, patience, and respect for clients 2	3Compassion, patience, and respect for clients 3	4Compassion, patience, and respect for clients 4	5Compassion, patience, and respect for clients 5
Overall caregiving competence	1Overall caregiving competence 1	2Overall caregiving competence 2	3Overall caregiving competence 3	4Overall caregiving competence 4	5Overall caregiving competence 5