Reference Form

The mission of the Volunteer Program is to support and enhance the services provided to patients, visitors, staff, and the community. Our volunteers play a large role in delivering quality services by providing a variety of volunteer services. Our volunteers must possess self-motivation and maturity. We appreciate your completing this form so that we may make a decision on the applicant’s ability to fulfill the responsibilities involved in our volunteer program.

Applicant's First and Last Name *

How long have you known the applicant *

In what capacity have you known the applicant *

Please evaluate the applicant in the following areas:

Displays courtesy, tact, patience *

Outstanding

Good

Fair

Needs Improvement

Works well with a diverse population *

Outstanding

Good

Fair

Needs Improvement

Exhibits interest and enthusiasm for a volunteer position *

Outstanding

Good

Fair

Needs Improvement

Accepts responsibility and commitment *

Outstanding

Good

Fair

Needs Improvement

Seeks opportunity to improve and advance *

Outstanding

Good

Fair

Needs Improvement

Accepts supervision in a positive way *

Outstanding

Good

Fair

Needs Improvement

Is dependable and punctual *

Outstanding

Good

Fair

Needs Improvement

Would you recommend this person for a volunteer position at University Medical Center of El Paso? *

Yes

Additional Comments: *

Evaluator's Printed First and Last Name: *

Phone Number: *

Today's Date: * +

Evaluator's Signature *

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