screening reference

Please fill out this form and click submit.

Thanks for taking a moment to complete this brief reference check.

Name (of person you are providing a reference for)

Your name

Your email

This address will receive a confirmation email

Your phone

Out of an abundance of caution with the intent of preventing false references, we may give the number provided a call to ensure that the name on the voicemail matches your name and leave a voicemail asking you to phone back if you did NOT provide a reference by email for the person listed above.

What is your relationship to the applicant?

How long have you known the applicant?

Please rate the individual based on your knowledge of the following traits:

Personal responsibility

Please select one option.

low acceptable good unknown

Trustworthiness

Please select one option.

low acceptable good unknown

Ability to relate to minors

Please select one option.

low acceptable good unknown

Ability to relate to vulnerable adults

Please select one option.

low acceptable good unknown

Would you trust the applicant to work with vulnerable minors or adults without any concern, reservation or hesitation?

Please select one option.

yes no

If you have any concerns regarding this person, please explain:

By checking this box

Please select all that apply.

I affirm that all info above is accurate. I acknowledge that my name in the electronic signature box below acts as a signature.

Electronic signature:

*** OFFICE USE ONLY BELOW ***

For use when checking references by phone or in person

Name of interviewer

Church role of interviewer

file, if in previous format

Upload (8MB)

Version# 2023-01-19 (appendix 2 in 2023 APP)

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Description

Please fill out this form and click submit.

screening reference

Description

Please Fix the Following