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17006 - ASSOCIATE TELEPHONE REFERENCE CHECK
Applicant's Name__________________________________________ Date:
Person Contacted:________________________________ Position/Title:
Organization: ____________________________________ Phone No:
____________________________________ has applied for the position of
_______________________ in our practice. Would you serve as a reference? Yes
No
Assure the reference that their comments will remain confidential.
Explain the job and ask how they think the person would fit into the position.
If appropriate, when did this individual work for you? From:____________
To:___________
What were the main job responsibilities that this person performed?
How would you describe the applicant's:
Attendance:
NOTE: Do not ask or collect information on Medical Leave Act absences or disability questions prohibited by the Americans with
Disabilities Act.
Dependability:
Capacity for discretion/good judgment:
Accuracy:
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