Letter of Reference

Applicant: Please Complete This Top Section Only.

Applicant's Name:

Applicant's Email:

Social Security No:

Name of Supervisor:

Title:

Name of Facility:

Facility Address:

I hereby authorize my past and present employers to provide information to
Richards Healthcare, Inc. about my job performance while in their
employment. I hereby release all such employers and their representatives
from all liabilities for issuing this information to Richards Healthcare, Inc.
I also authorize Richards Healthcare, Inc. to disclose this information
to client facilities for which I have expressed an employment interest.

Applicant's Signature:

Date:

Employer Please Note: The above named individual
has applied to Richards Healthcare, Inc. for employment
in the healthcare field and has submitted your name
as an employer for reference. We would greatly 
appreciate it if you would take a few moments to
complete the following questions. Please return this 
completed form to the address listed below.

Ability to Work Well with Others:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Accurate and Thorough Documentation:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Adaptability to Patient Assignment:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Attendance and Punctuality:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Attitude:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Clinical Skills:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Communication Skills:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Cooperation:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Dependability:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Flexibility:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Leadership Abilities:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Problem Solving Skills:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Professional Appearance:

EXCELLENT
ABOVE ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Work Quality:

EXCELLENT
ABOVE AVERAGE
SATISFACTORY
NEEDS IMPROVEMENT

Date of Employment:

TO: