Thank you for taking the time to fill out this referral form. As you know, working with children in an educational relationship is both exciting and a big responsibility! We appreciate your fullest honesty in answering these questions. Thank you.

Your Name and Title: *

Job applicant's name (person you are referring): *

Do you wish your comments to be confidential - or shared with applicant? *

Keep comments confidential

Share my answers with applicant

How long (from when to when) did you/have you known the applicant? *

Effectiveness: How effectively did this person complete daily tasks? *

Frequently leaves tasks unfinished, disorganized.

With supervision, can complete normal tasks.

Can complete normal tasks with no supervision.

Able to assess the company needs, see where work is needed and complete tasks without supervision.

Cooperation: How well does this person work with others in a group? *

Cooperates grudgingly; makes trouble; obstructs group efforts.

Cooperates somewhat, but tends to choose own interests over common good.

Cooperates actively; helps things run smoothly.

Exceptionally successful in working with others and inspiring confidence.

Responsibility/trustworthiness: How responsible is this person? *

Irresponsible even under supervision.

Usually needs detailed instructions with regular checks of work.

With supervision will do satisfactory work.

Carries out routine activity on own responsibility.

Exceptionally able to accomplish work without close supervision.

Willingness to improve: How does this person react to suggestions/criticism by others? *

Takes feedback as a personal insult, gets defensive.

Listens to suggestions openly but does not apply them/make changes. (Performance stays the same.)

Follows suggestions and makes changes willingly when appropriate. (Performance improves.)

Proactive: Actively seeks feedback: asks for criticisms and suggestions and implements them.

Stability: How well does this person control emotions? *

Tends to over-respond (to stress, good fortune, etc.); is over-emotional.

Tends to be unresponsive; apathetic.

Has difficulty expressing emotions; over-controlled.

Usually well-balanced.

Excellent balance of both responsiveness and self-control.

Boundaries and Balance: How well does this person manage work/life balance? *

Personal life frequently interferes with work/school performance, attendance or obligations.

Personal life periodically affects performance, attendance or obligations. Deadlines are missed.

Personal life rarely affects work performance. Deadlines and responsibilities are met.

Personal life does not affect work performance or deadlines.

Strengths: Please describe the applicant’s strengths. *

Areas of Improvement: Please describe where the applicant could show areas of improvement.

Do you have any additional comments about this applicant?

Thank you for your time!

Start your lessons and experience the magic of music!

Meridee Winters School of Music, 63 W. Lancaster Ave. #7, Ardmore, PA 19003610-649-2782merideemusic@merideewinters.com

Meridee Winters School of Music • 63 W. Lancaster Ave. #7, Ardmore, PA 19003 • 610-649-2782 merideemusic@merideewinters.com • Text: 610-467-9863
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