Employment Reference Questionnaire

Employer Reference Questionnaire

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Thank you for taking the time to complete our questionnaire. We rely upon well-informed individuals like you to assist us in the selection of personnel who are qualified for public service and who will maintain high standards of performance in the public safety profession.

Employer/Supervisor Reference

Enter details about the person you a providing a reference for

Candidate Name*

First Last

Is the candidate currently employed?*

Do you know the date(s) the candidate's employment begun and/or ended?*

Date Employment Begun*

MM slash DD slash YYYY

Date Employment Ended*

MM slash DD slash YYYY

Was a two-weeks notice given?*

Company Details

Name of Business/Company*

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone Number*

Fax Number

Email*

Your Contact Details

Please fill in your contact information

What is your name?*

First Last

What is your role at the business/company?*

Your Phone Number

Your Email Address*

Work Performance

Please rate the applicant on their work performance using the options Excellent, Good, Fair, Poor, or Unknown. Any rating of Poor or Excellent will require further explanation and/or information.

Punctuality*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Attendance*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Appearance / Physical Fitness*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Dependability*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Overall Attitude/ Work Ethic*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Problem Solving Skills*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Resourcefulness*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Adapts to Change/ Willingness to Learn*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Attention to Detail*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Decision Making Skills*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Following Directions*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Take Charge When Needed*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Handle Problems/ Tasks in Stressful Situations*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Maintain Emotional Control*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Performing complex tasks under stressful conditions*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Working with the critically injured / ill*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Self-Motivated/ Takes Initiative*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Critical decision making under stressful conditions*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Judgment / Common Sense*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Handling Sleep Deprivation/ Shift Work*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Responds to Constructive Criticism*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Personal Accountability for Actions*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Degree of Supervision Needed*

None

Little

Moderate

Full Time

Unknown

Additional Information*

Communication Skills

Please rate the applicant on their communication skills

Verbal*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Written*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Radio*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Relationships/ Interpersonal Skills

Please rate the applicant on their relationships/ interpersonal skills.

Co-workers*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Supervisors*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Public*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Work as a team member*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Character

Please rate the applicant on their character.

Honesty/ Integrity/ Ethics*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Trustworthy*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Follow through on Commitments*

Excellent

Good

Fair

Poor

Unknown

Additional Information*

You provided a 'fair' response, which indicates 'average' or just 'above average', can you expand your response further?

Diversity / Sensitivity

Display Bias Based On

Race / Ethnicity*

Never

Little

Some

Always

Unknown

Additional Information*

Gender*

Never

Little

Some

Always

Unknown

Additional Information*

Religious Beliefs*

Never

Little

Some

Always

Unknown

Additional Information*

Sexual Orientation*

Never

Little

Some

Always

Unknown

Additional Information*

Age*

Never

Little

Some

Always

Unknown

Additional Information*

General Questions

Please provide further details to any “no” answer

Would you rehire the candidate or recommend the candidate for rehire?*

Additional Information*

Did the Candidate give a two-week notice?*

Additional Information*

Can the Candidate be assertive and confront a problem when necessary?*

Additional Information*

Do you feel the Candidate will be effective in a job where helping other people is a key responsibility?*

Additional Information*

Can the Candidate function in a team environment?*

Additional Information*

Can the Candidate work with person of a different cultural background or of the opposite sex?*

Additional Information*

Would you trust this Candidate with your own personal safety or that of your family?*

Additional Information*

Would this person be a good fit for a Public Safety position?*

Additional Information*

Do you consider the Candidate to be a person of integrity and/or honest person?*

Additional Information*

Do you have complete trust in this person?*

Additional Information*

General Questions

Please provide further details to any “yes” answer

Was the Candidate terminated, asked to resign, or permitted to resign in lieu of termination?*

Additional Information*

Has the Candidate been subject of any form of disciplinary action?*

Additional Information*

Did/Does the Candidate have any problems following/adhering to company policy?*

Additional Information*

Did/Does the Candidate have any extended work absences? (Do NOT include periods of disability, legitimate illness, or maternity leave.*

Additional Information*

Are you aware of any current or past alcohol abuse issues?*

Additional Information*

Are you aware of any current or past illegal drug use with Candidate?*

Additional Information*

Are you aware of any current or past prescription drug abuse with Candidate?*

Additional Information*

Have you seen the Candidate lose control of their emotions?*

Additional Information*

Have you ever seen or heard of this Candidate doing or saying anything inappropriate?*

Additional Information*

Has the Candidate expressed or displayed any bias or prejudice towards others?*

Additional Information*

Can you think of any reason why this Candidate should not be offered this job?*

Additional Information*

Do you have any information that you would like to discuss directly with the background investigator privately?*

Additional Information*

What is the Candidate’s strongest character feature?*

What is the Candidate’s weakest character feature?*

Please provide at least two additional references who know the Candidate. Please provide full name, telephone, and email address.*

Full Name

Phone

Please provide additional information about the Candidate that you feel might be relevant to the background investigation.*

The Gumshoe Group!

Employment Reference Questionnaire

Employer Reference Questionnaire

Employer/Supervisor Reference

Company Details

Your Contact Details

Work Performance

Communication Skills

Relationships/ Interpersonal Skills

Character

Diversity / Sensitivity

General Questions

General Questions