Professional Reference Form - Direct Care

Your Name *

Applicant's Name *

Applicant's Employment Dates at Your Place of Work *

(Month/Year to Month/Year)

What were their primary responsibilities? *

How would you evaluate their overall work performance? What are their greatest strengths? *

What are some of their weak points/areas in need of improvement? How do they react to criticism? *

How did they interact with coworkers? *

What was this applicant's reason for leaving? *

Would this applicant be eligible for rehire at your place of work? *

How does this applicant relate with children/youth? *

Does this applicant have the ability and characteristics to be a good influence on children/youth? *

Has this applicant had substantiated allegations of sexual abuse or sexual harassment, made against them in a prison, jail, lock-up, community confinement facility, juvenile facility, or other institution, including employment with your organization? *

Yes

Not that I am aware of

Comments

Has this applicant been convicted OR civilly or administratively adjudicated, for engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? *

Yes

Not that I am aware of

Comments

Has this applicant ever resigned during a pending investigation of an allegation of sexual abuse or sexual harassment? *

Yes

Not that I am aware of

Comments:

Main Office

Omaha Office

Phone

Email