Reference Check Form
Instructions: Thank you for serving as a reference. To complete the form, tab to each section and enter the requested information.
Text fields will expand as you type if more space is needed for your input.
Position #
Applicant’s Name:
Company Contacted:
Title of Person
Contacted:
Employment Dates:
Position Applied For:
Position Held:
Person Contacted:
Phone/Email:
From (mm/yyyy)
To (mm/yyyy)
Was she/he classified as an Exempt or Non-exempt employee?
Major Responsibilities:
Reason for Leaving:
Competency
Exempt
Full Time
Part Time
Non-exempt
*Rating scale: Excellent = 4, Satisfactory = 3, Fair = 2, Unsatisfactory = 1, Not Applicable = N/A
Rating*
Comments, as needed
1. Plan and Organize
2. Interpersonal Relationships
3. Dependability
4. Job tasks proficiency
5. Communication Skills
6. Administrative Skills
7. Technology Skills
8. Supervisory Skills
# of People Supervised
9. Leadership Skills
10. Teaching Skills
What are her/his strengths?
What are her/his areas for opportunity?
Is she/he eligible for rehire?
If no, why not?
Additional comments:
Signature
Date
After completing the reference, please email it, fax it, or send it based on the information provided by your MCCCD contact.
MCCCD HR Administration/Strategic Staffing
November 2013