Holland Bloorview Kids Rehabilitation Hospital
Family Leader Volunteer Reference Form

Volunteer Resources would appreciate your assistance in providing us with a reference on behalf of an applicant/prospective volunteer. To be completed by an employer, supervisor, teacher or individual who has known the applicant in a professional, volunteer or community capacity. All information provided is CONFIDENTIAL.

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* 1. Name of Applicant you are completing reference for:

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* 2. Your Contact Information

Name:

Organization:

Job Title:

E-mail (For reference contact purposes only):

Phone #:

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* 3. How long have you known this applicant?

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* 4. In what capacity do you know this applicant?

Employment

Academic

Community Involvement

Other (please specify)

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* 5. I know the applicant:

Very well

Well

Casually

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* 6. Please rate the following:

	Excellent	Very Good	Good	Fair	Poor	N/A
Commitment	Commitment Excellent	Commitment Very Good	Commitment Good	Commitment Fair	Commitment Poor	Commitment N/A
Initiative	Initiative Excellent	Initiative Very Good	Initiative Good	Initiative Fair	Initiative Poor	Initiative N/A
Ability to maintain confidentiality	Ability to maintain confidentiality Excellent	Ability to maintain confidentiality Very Good	Ability to maintain confidentiality Good	Ability to maintain confidentiality Fair	Ability to maintain confidentiality Poor	Ability to maintain confidentiality N/A
Adaptability	Adaptability Excellent	Adaptability Very Good	Adaptability Good	Adaptability Fair	Adaptability Poor	Adaptability N/A
Interactions with authorities	Interactions with authorities Excellent	Interactions with authorities Very Good	Interactions with authorities Good	Interactions with authorities Fair	Interactions with authorities Poor	Interactions with authorities N/A
Attitude	Attitude Excellent	Attitude Very Good	Attitude Good	Attitude Fair	Attitude Poor	Attitude N/A
Compassion	Compassion Excellent	Compassion Very Good	Compassion Good	Compassion Fair	Compassion Poor	Compassion N/A
Interactions with persons with disabilities	Interactions with persons with disabilities Excellent	Interactions with persons with disabilities Very Good	Interactions with persons with disabilities Good	Interactions with persons with disabilities Fair	Interactions with persons with disabilities Poor	Interactions with persons with disabilities N/A
Interactions with clients/customers	Interactions with clients/customers Excellent	Interactions with clients/customers Very Good	Interactions with clients/customers Good	Interactions with clients/customers Fair	Interactions with clients/customers Poor	Interactions with clients/customers N/A
Interactions with peers	Interactions with peers Excellent	Interactions with peers Very Good	Interactions with peers Good	Interactions with peers Fair	Interactions with peers Poor	Interactions with peers N/A

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* 7. What is the applicant's greatest strength:

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* 8. What is the applicant's greatest opportunity for improvement:

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* 9. Family Leaders may perform any of the following roles:
1. Provide advice to committees or working groups (which may include senior management, frontline staff and/or families) to help shape policies or programs;
2. Share their personal story in a variety of settings in order to impact service delivery throughout Holland Bloorview and in the broader healthcare system;
3. Review and advise on future ongoing research projects by drawing on their lived experience to provide feedback.

Do you have any reason to think it would not be a good idea to have this person volunteer in any of these types of roles?

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* 10. Would you consider hiring/rehiring this person?

Yes

N/A

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* 11. Other comments:

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* 12. Do you agree to be contacted by Holland Bloorview to discuss this reference if needed?

Yes

I understand that any wilful misrepresentation made by me in connection with this reference will be sufficient cause for the dismissal of the applicant from Volunteer Resources.

Thank you for providing a reference. Volunteers are an important part of the work Holland Bloorview does.

Holland Bloorview Kids Rehabilitation HospitalFamily Leader Volunteer Reference Form

Question Title

* 1. Name of Applicant you are completing reference for:

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* 2. Your Contact Information

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* 3. How long have you known this applicant?

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* 4. In what capacity do you know this applicant?

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* 5. I know the applicant:

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* 6. Please rate the following:

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* 7. What is the applicant's greatest strength:

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* 8. What is the applicant's greatest opportunity for improvement:

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* 10. Would you consider hiring/rehiring this person?

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* 11. Other comments:

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* 12. Do you agree to be contacted by Holland Bloorview to discuss this reference if needed?

Holland Bloorview Kids Rehabilitation Hospital
Family Leader Volunteer Reference Form