Reference Request

The individual named below has applied for employment with one of the AMN Healthcare brands and has named you as a reference contact. Please complete all required fields and submit the form by clicking on the submit button. Your response will be held in the strictest confidence.

Requestor Profile Edit

Name:
Email:

Job Category:
Profession:
Specialty:

First Name Please enter a First Name

Last Name Please enter a Last Name

Job Category Select a Job Category

Profession Select a Profession

Specialty Select a Specialty

Your Profile Edit

Name:
Email Address:
Position Title:

Phone #:
Secondary Phone #:

First Name Please enter a First Name

Last Name Please enter a Last Name

Position Title Please enter your Position Title

Email Address
Please enter an Email

Phone # Please enter a Primary Phone

Secondary Phone #

Facility/Employer Edit

Name:

Location: , {{editEvaluationInfo.WorkHistory.TRMNG__StateProvince__c}} {{editEvaluationInfo.WorkHistory.TRMNG__PostalCode__c }}

Name
Please enter a Facility Name

City
Please enter a City

State/Province
Please enter a City

Zip
Please enter a ZipCode

Unit Profile Work Setting/Department Edit

Unit/Floor/Dept. name: Work Setting/Department:
Position held/Job title:
Unit description: Job Responsibilities:

Number of beds in Unit:
# of patients/shift:

Employed: From to

Unit/Floor/Dept. name Work Setting/Department This Field is required

Position held/Job title
This Field is required

# of patients/shift Please enter # of patients/shift If not applicable, please select n/a.

Number of beds in Unit
This Field is required

Dates Employed From Please enter Employed Start Date

Dates Employed To Please enter Employed End Date (To date not required if currently working)

Unit description Job Responsibilities
Please enter a Unit Description May include common patient diagnoses, patient acuity, special equipment used, special skills/competencies, etc.

Professional Reference

KEY: A = Superior B = Exceeds Standards C = Meets Standards D = Does Not Meet Standards

A	B	C	D

A rating is required

Age Level Competency

At least one competency is required

Yes No

I II III IV V

If you had the opportunity, would you rehire the candidate for a similar position?
Yes No This field is required

Please explain This field is required

Please include any additional comments about the healthcare professional

Thank you. Your evaluation has been received.

No action is needed for this evaluation at this time.