HR-12
Rev JAN 21
Page 1 of 2
LOUISIANA DEPARTMENT OF HEALTH
REFERENCE CHECK FORM
Date ______________________________
Applicant Name:
Position Applied for:
__________________________________________________ ____________________________________________________________________
Upon completion of the interview process a pre-employment reference check may be made of the selected candidate. The reference check shall be
limited to the following information:
Current/Last Employer:
Telephone#:
Person Contacted:
Title:
Dates of Employment:
From:
To:
Position Held:
Salary:
1. What is/was your employment relationship with this person (current or former supervisor, second-line supervisor, etc.)?
2. What is/was the nature of his/her position/duties?
3. How would you describe the accuracy of his/her work?
4. How well does/did he/she respond to pressure (e.g., from high volume, deadlines, multiple tasks, public contact)?
5. How well was his/her work planned and organized, and were assignments completed timely?
6. What is/was the amount and type of supervision required for him/her?
7. How well does/did he/she get along with other people (e.g., clients, co-workers, supervisors)?
8. How does/did he/she respond to criticism/interpersonal conflict?
HR-12
Rev JAN 21
Page 2 of 2
9. What are/were his/her strongest skills as an employee?
10. What areas of his/her performance needed improvement?
11. How would you describe his/her attendance and punctuality? NOTE: Do not ask or collect information on Family Medical Leave Act absences
or disability questions prohibited by the Americans with Disabilities Act.
12. What was the reason for leaving your employment?
13. Would you rehire him/her?
14. Any other comments you would like to include?
REFERENCE CHECKED BY:
Name:
Title:
Signature:
Date
