* = Required Information
Last Name
*
First Name
*
Section A: Candidate, please complete Section A only and forward directly to:
I,
hereby authorize my current and previous employers to release information regarding my work performances to Conan Home Health Inc. I release all such employers from any liability for issuing this information to Conan Home Health Inc Also, I hereby permit Conan Home Health Inc. to share this information with client facilities.
Name
*
Social Security Number
*
Employer
*
Position Held
*
Address
*
Phone Number
*
Contact Person
*
Title
*
Applicant Name
*
Section B: (To be completed by employer). Thank you for completing this form as it assists us in ensuring that all professional accepted into our agency are of the highest caliber. Your responses will remain in strictest confidence.
Please Rate The Candidate
Clinical skills
Above Average
Average
Below Average
Ability to prioritize
Above Average
Average
Below Average
Flexibility to work different assignment
Above Average
Average
Below Average
Initiative and enthusiasm
Above Average
Average
Below Average
Ability to relate to patients
Above Average
Average
Below Average
Cooperation with staff
Above Average
Average
Below Average
Ability to take Charge
Above Average
Average
Below Average
Punctuality
Above Average
Average
Below Average
Comments
Eligible for Rehire
Yes
No
Reason for Leaving
Name
*
Title
*
Date
Submit