Date ______________________
Search No. _________________
University of Northern Iowa
SAMPLE REFERENCE CHECK FORM
Applicant Name: ______________________________________________________________________________
Name of Reference and Phone # __________________________________________________________________
Relationship to applicant: □ Supervisor
_____________________
□
Co-Worker
□
Academic
□
Other (Describe): -
Dates of Employment (if applicable): ______________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Eligible for Rehire:
Yes 
No 
Script for how to answer the following:
I am going to ask you a few questions about (applicant’s name). These include aspects such as attendance and
leadership. For each aspect of the job, please tell me if (applicant’s name)’s performance is/was excellent,
satisfactory, needs/needed improvement, or unsatisfactory.
RATING
Attendance
Communication
Dependability
Leadership
Quality of work
Quantity of work
EXCELLENT
SATISFACTORY
NEEDS
IMPROVEMENT
UNSATISFACTORY
UNABLE TO
COMMENT
Teamwork
Additional Questions for Reference:
1. Describe the type of work the candidate was responsible for?
2. Did the individual earn any promotions or special recognition?
3. How would you describe the individual’s overall performance?
4. This position entails __________. Would you recommend him/her for this position?
5. Additional comments?
____________________________________________
Signature of Person Completing Form
________________
Date