Advanced Practice Provider Candidate Reference Check

General Information

Date

Applicant Name: (person you are completing this evaluation for)

Applicant Specialty:

Evaluator Name:

Evaluator Title: (if applicable)

Evaluator Email:

Evaluator Daytime Phone:

Relationship to Applicant/Reference Type: (Choose one)

*If other, please specify:

How do you know the applicant?

How long have you known the applicant?

When was the last contact you had with the applicant? (Indicate a date)

Answer the following questions based on your interactions/knowledge of the applicant.

How would you describe the applicant’s work ethic?

What are some of the applicant’s strengths?

What are some areas of improvement that you see for the applicant?

How would you describe the applicant’s interpersonal skills?

How would you describe the applicant’s rapport with patients?

How would you describe the applicant’s interaction with colleagues & peers (includes nurses, non-clinical staff and physician peers/partners?

Do you recommend this applicant for this position?

Additional comments/concerns/information to share regarding this applicant?