DearSirorMadam:

Thankyouforagreeingtobeareferenceforourvolunteer.Pleasecompletethisentireform.Our
volunteersmusthaveatleasttwowrittenreferencesonfilebeforetheycanprovideservicewithour
organization.Yourreferencecheckformmustbereturnedtothepotentialvolunteer,attn:Volunteer
Coordinator,inasealed(unopened)envelopewithyoursignaturewrittenacrosstheseal.Your
response(within1weekuponreceiptofthisform)isgreatlyappreciated.
PotentialVolunteersName:___________________________________________________________
ReferenceName:_________________________________________Title:_______________________
Organization:_______________________________________________________________________
Address:___________________________________________________________________________
City:________________________________State:______________________Zip:_______________
Phone:___________________Fax:____________________Email:___________________________
Pleasecheckonecolumnperquestion:

Questions

Unsatisfactory Satisfactory Excellent

Howwouldyourankthisindividual'squalityof
work?
Howwouldyourankthisindividual's
dependability?
Whatis/wasthisindividualliketointeractwithasa
coworker,employee,associate,orstudent?

Howis/wasthisindividual'sinvolvementwith
clients/patients/customers/others?

Howwouldyourankthisindividual'sleadership
capabilities?

Howlonghaveyouknowthisindividual?________________________________________________
Whatisyourrelationshiptothisindividual?_______________________________________________
Inordertoensurethehighestpossiblequalityofcareforourpatients,pleasebrieflydescribeanyareas
ofconcernthatweshouldknowaboutregardingthisindividual._______________________________
__________________________________________________________________________________
Wouldyourecommendthisindividualforavolunteerpositionwithourorganization?_____________
Additionalcommentscanbewrittenontheback.
ReferencesSignature:_____________________________________Date:_______________________

7/8/2011