Reference Form TO THE APPLICANT - Breakthrough Developmental ...

Reference Form

TO THE APPLICANT: All applicants are required to submit three completed reference forms to Breakthrough Developmental Services, LLC. Think carefully about who you ask to fill them out. This form should be given to someone who knows you well and to whom you are not related. Select someone who is familiar with your personal background, education, employment, and/or professional skills. Your reference should complete the form and return it to our offices. Applicant’s Information Full Name:

Phone:

Address: Position applying for: (This section is optional) Waiver of Right to Access: I, the undersigned, hereby voluntarily waive any right or privilege to inspect or challenge the content and comments expresses in this reference. I expect that the observations made shall remain confidential between the reference and Breakthrough Developmental Services, LLC. Signature:

Date:

Signing this waiver is voluntary. It is not required as a condition for hiring. TO THE REFERENCE: The person named above is applying to work with Breakthrough Developmental Services, LLC, a company which provides services to children and their families affected by intellectual, developmental, and learning disorders as well as challenging behaviors. By providing you with this form, the applicant has indicated that you would be able to evaluate his or her qualifications and provide us with a candid recommendation. As this reference will be most valuable to us when it is completed as honestly as possible, we ask that you be as objective as possible when appraising the applicant’s assets and limitations in regard to the goals and conditions listed below. Feel free to make any additional comments on this form and to attach additional sheets if necessary. Your input is greatly appreciated!

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Reference’s Information Your Name: Your Address:

Phone: City:

State:

In what capacity have you known the applicant? q Pastor q Supervisor

Zip:

Approximately how long have you known the applicant?

q Friend q Other __________________

PLEASE RETURN THIS FORM TO: Breakthrough Developmental Services, LLC Attn: Human Resources Department P.O. Box 5124 Hyattsville, MD 20782 Phone: 240-355-0834 or 1-855-255-5270 Fax: 1-855-513-1069

Check any traits listed that characterize the applicant. q q q q

Impulsive Friendly Mature Flexible

q q q q

Self-starter Moody Low self-esteem Sensitive and caring

q q q q

q Argumentative q Extrovert q Introvert

q Pleasant to be with q Shy, reserved q Follower

q q q

q Relates well to other races/cultures q Motivated

q Often needs emotional support q Joyous

q

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Quick-tempered Lazy Easily discouraged Uses inappropriate humor Has respect for others Leader Constantly complaining Dependable

q Productive

Top three strengths A. ________________________________________________________________________ B. ________________________________________________________________________ C. ________________________________________________________________________ Top three weaknesses A. ________________________________________________________________________ B. ________________________________________________________________________ C. ________________________________________________________________________ Evaluation of applicant

Productive Ability to work independently Initiative Application of skills and knowledge Capacity for development Attendance Dependability in carrying out assignment Ability to work with and for others Flexibility – adaptability Ability to solve problems – resourcefulness Originality Judgment Ability to communicate effectively Supervisory ability

3

No basis for judgment

Below average

Average

Better than average

Outstanding

Elements

Please place a check in each box that describes the applicant. You may check more than one box, if necessary. Personal Relationships 1. Peer relationships 2. Social relationships q Very popular q Socially adept q Makes friends easily q Well mannered q Slow to make friends q Average q Generally avoided q Awkward in social situations q Avoid social relationships 3. Relationships with 4. Relationships with the 5. Interpersonal relationships opposite gender same gender q Overbearing q Relates well q Relates well q Average q Sensitive/considerate but q Sensitive/considerate but q Loner awkward awkward q Outgoing, friendly q Feels at ease q Feels at ease q Reserved q Insensitive/insecure q Insensitive/insecure Emotional Maturity 6. Response to stress/pressure 7. Self-assurance q Copes well q Confident q Dominates situation or people q Needs encouragement q Withdraws socially or emotionally q Average q Adapts slowly q Insecure q Becomes overly critical of others Working with Others 8. Ability to work with supervisors 9.Working relationships q Independent worker; able to take directions q Works well with others and go q Has average ability to work with others q Cooperative in most situations q Sometimes has difficulty interacting with q Rebellious spirit; likes to do his/her own others thing q Has problems relating to fellow workers 10. Supervisory needs 11. Communication Skills q Needs little close supervision, only q Clear, confident in communicating direction q Average in ability communicate q Does well with regular, routine supervision q Unable to communicate clearly q Needs accountability and encouragement to accomplish tasks/goals q Needs excessive supervision Leadership 12. On a team or two to four people, this 13. When conflict arises, this person generally person would likely be: responds with: q The leader q Peacemaking q A self-starting team member q Confrontation q A supportive team member q Withdrawal/Avoidance q A low-initiative follower q Openness to resolving conflict q Lack of cooperation q Defensive/Critical attitude 4

Would you be willing to employ or re-employ this person if you had an opening requiring the general professional level and profession of the applicant? q Yes q No ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Overall recommendation q I recommend the applicant without reservation as an excellent candidate for a position with Breakthrough Developmental Services, LLC. q I recommend the applicant as a good candidate for a position with Breakthrough Developmental Services, LLC. q I have some reservations, but I believe the applicant has a reasonable chance of success. q I have some substantial doubts about the applicant. q I do not recommend this applicant for Breakthrough Developmental Services, LLC. Additional Comments (Please attach an additional page, if needed) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ____________________________________ Signature Verified by: Signature:

____________________________________ Date

For Office Use Only Date:

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