Certified Reference Form

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Certified Reference Form REF-CE-93-12

HUMAN RESOURCES – JOHNSTON COUNTY SCHOOLS


PO BOX 1336
SMITHFIELD, NC 27577
PHONE: 919-934-6031
FAX: 919-989-1095

TO THE APPLICANT: Complete the applicant section and direct this form to one of the individuals you have selected as a
reference.

Applicant’s Full Name: _______________________________________________________ SSN _______-_______-_______


Applicant’s Address: ___________________________________________________________________________________
______________________________________________________ Phone _______/_______________
Applying For Position As: _____________________________________________________________________________
TO THE REFERENCING INDIVIDUAL: Please respond to each of the areas below, giving your candid opinion of the applicant’s
qualifications for the position indicated above. References for administrative or
supervisory positions should be in narrative form. Thank you for your assistance.
Please check the level at which the applicant
Superior Well Above Above Standard Below Unsatisfactory
consistently performs.

Management of Instructional Time


Management of Student Behavior
Presentation of Instruction
Monitoring of Student Performance
Provision of Feedback to Students
Evidence of Planning, Use of Resources
Interaction with Students and Co-workers
Assumption of Non-Instructional Duties
Evidence of Professional Growth
Enthusiasm for Teaching
Communication Skills (Written and Oral)
Scholarship
Character (General Conduct, Ethics, Morals)
Overall Evaluation

Special Strengths _______________________________________________________________________________________________

Weakness(es) __________________________________________________________________________________________________

In what capacity have you known the applicant? ______________________________________________________________________

If you were personally responsible, would you recommend the employment of this applicant? __________________________________

Other Comments _______________________________________________________________________________________________

Name (Please print.) ________________________________________________________ Date _____________________________

Signature ________________________________________________________________

Positions ________________________________________________________________

Address _________________________________________________________________

________________________________________________________________

Work Phone ______/__________________ Home Phone ______/__________________

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