Employment Review Applicant Name* First Last Healthcare Facility*Dates of EmploymentThis field is hidden when viewing the formSupervisor Name and TitleLocation*Phone #*Name*Title*SupervisorDirectorCharge NurseCo-WorkerThis field is hidden when viewing the formIs the employee eligible for rehire?* Yes No This field is hidden when viewing the formPlease rate the ProfessionalQuality of Work* Excellent Good Average Below Average Poor Attitude / Cooperation* Excellent Good Average Below Average Poor Ability to work with Others* Excellent Good Average Below Average Poor Dependability* Excellent Good Average Below Average Poor Personal Appearance* Excellent Good Average Below Average Poor Attendance / Punctuality* Excellent Good Average Below Average Poor Work Ethic* Excellent Good Average Below Average Poor Patient Care* Excellent Good Average Below Average Poor Comments: