Performance Evaluation & Professional Reference

Reference Name*

First Last

Today's Date*

Title*

Unit*

Facility Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nurse's Name*

First Last

The nurse or applicant entered above has either applied for a nursing position at Republic Health Resources or is currently working as a Travel Nurse or Consultant for Republic at your facility. The applicant signed a release for us to obtain information from you, and we would appreciate it if you would complete this performance evaluation/reference.

What was the applicant's position during his/her employment with you?*

Employment Start Date*

Employment End*

Would you rehire the applicant?*

Yes
No

Reason this applicant left your employment (if applicable)

Quality of Work*

Productivity/Time Management*

Professionalism*

Ability to Handle Stress*

Flexibility*

Dependability/Follow Through*

Team Member Skills*

Communication Skills*

Attendance/Punctuality*

Appearance*

Interpersonal Skills/Attitude*

Documentation Skills*

Technical Nursing Competency/Skills*

Comments (Please provide a professional profile of the applicant in 3-4 sentences)*

Reference's/Evaluator's Name*

Reference's/Evaluator's Email*

Reference's/Evaluator's Phone*

Reference's/Evaluator's Name Signature*

Performance Evaluation / Professional Reference

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