Your First and Last Name: 
                       
                    
                      Your Address: 
                      
                       
                     
					
                      Your State: 
                      
						  
					          	Alabama 
								Alaska 
								Arizona 
								Arkansas 
								California 
								Colorado 
								Connecticut 
								Delaware 
								District Of Columbia 
								Florida 
								Georgia 
								Hawaii 
								Idaho 
								Illinois 
								Indiana 
								Iowa 
								Kansas 
								Kentucky 
								Louisiana 
								Maine 
								Maryland 
								Massachusetts 
								Michigan 
								Minnesota 
								Mississippi 
								Missouri 
								Montana 
								Nebraska 
								Nevada 
								New Hampshire 
								New Jersey 
								New Mexico 
								New York 
								North Carolina 
								North Dakota 
								Ohio 
								Oklahoma 
								Oregon 
								Pennsylvania 
								Rhode Island 
								South Carolina 
								South Dakota 
								Tennessee 
								Texas 
								Utah 
								Vermont 
								Virginia 
								Washington 
								West Virginia 
								Wisconsin 
								Wyoming 
						   
                       
                     
                    
                      Candidates First and Last Name: 
                       
                    
                      Today's Date: 
                      
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                      Contact Phone Number 1: 
                       
                    
                      E-mail: 
                       
                    
                      (Must  provide a verifiable contact number in order for reference to be approved!) 
                     
                    
                      Is this a personal or work related reference? 
                      
                          Personal 
                          Childcare Work 
                          Non-Childcare Work 
                         
                       
                    
                      If this is a personal related reference please specify the relation you have to the candidate: 
                      
                          Neighbor 
                          Friend 
                          Relative 
                          Other 
                         
                       
                    
                      How many years do you know the candidate: 
                       
                    
                       If this is a childcare related reference please answer the following 4 questions as well. If this is a personal reference you can skip the next 4 questions. 
 
                    
                       
                    
                      Between what dates did the applicant work for you? 
                      
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                        to
                        
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                      Was this position permanent or temporary? 
                       
                    
                      Was it full time or part time? 
                       
                    
                       Names and Ages of Children When Candidate Started 
 
                    
                       Typical Hours of the Position 
 
                    
                       Were any additional duties performed as part of her position?  Please check duties performed 
 
                    
                       
                    
                       
                    
                       Please list four adjectives that best describe the personality of the applicant: 
                                Dependable 
                                Reliable 
                                Cheerful 
                                Loyal 
                                Accommodating 
                                Trustworthy 
                                Punctual 
                                Honest 
                                Responsible 
                                Supportive 
                                Nurturing 
                                Helpful 
                                Good Communicator 
                                Positive 
                                Patient 
                                Committed 
                                Organized 
                                Able to Multi-Task 
                                Involved 
                                Educator 
                                Role-Model 
                                Creative 
                                Professional 
                                Kind 
                                Ethical 
                                Sensible 
                                Dedicated 
                                Genuine 
                                Mild Mannered 
                                Entertaining 
                                Energetic 
                                Considerate 
                                Thoughtful 
                                Understanding 
                                Flexible 
                                Adaptable 
                                Resourceful 
                                Qualified 
                                Interactive 
                                Conscientious 
                                  
                               
                        ,
                        
                          Dependable 
                          Reliable 
                          Cheerful 
                          Loyal 
                          Accommodating 
                          Trustworthy 
                          Punctual 
                          Honest 
                          Responsible 
                          Supportive 
                          Nurturing 
                          Helpful 
                          Good Communicator 
                          Positive 
                          Patient 
                          Committed 
                          Organized 
                          Able to Multi-Task 
                          Involved 
                          Educator 
                          Role-Model 
                          Creative 
                          Professional 
                          Kind 
                          Ethical 
                          Sensible 
                          Dedicated 
                          Genuine 
                          Mild Mannered 
                          Entertaining 
                          Energetic 
                          Considerate 
                          Thoughtful 
                          Understanding 
                          Flexible 
                          Adaptable 
                          Resourceful 
                          Qualified 
                          Interactive 
                          Conscientious 
                            
                         
                        ,
                        
                          Dependable 
                          Reliable 
                          Cheerful 
                          Loyal 
                          Accommodating 
                          Trustworthy 
                          Punctual 
                          Honest 
                          Responsible 
                          Supportive 
                          Nurturing 
                          Helpful 
                          Good Communicator 
                          Positive 
                          Patient 
                          Committed 
                          Organized 
                          Able to Multi-Task 
                          Involved 
                          Educator 
                          Role-Model 
                          Creative 
                          Professional 
                          Kind 
                          Ethical 
                          Sensible 
                          Dedicated 
                          Genuine 
                          Mild Mannered 
                          Entertaining 
                          Energetic 
                          Considerate 
                          Thoughtful 
                          Understanding 
                          Flexible 
                          Adaptable 
                          Resourceful 
                          Qualified 
                          Interactive 
                          Conscientious 
                            
                         
                        , 
                          Dependable 
                          Reliable 
                          Cheerful 
                          Loyal 
                          Accommodating 
                          Trustworthy 
                          Punctual 
                          Honest 
                          Responsible 
                          Supportive 
                          Nurturing 
                          Helpful 
                          Good Communicator 
                          Positive 
                          Patient 
                          Committed 
                          Organized 
                          Able to Multi-Task 
                          Involved 
                          Educator 
                          Role-Model 
                          Creative 
                          Professional 
                          Kind 
                          Ethical 
                          Sensible 
                          Dedicated 
                          Genuine 
                          Mild Mannered 
                          Entertaining 
                          Energetic 
                          Considerate 
                          Thoughtful 
                          Understanding 
                          Flexible 
                          Adaptable 
                          Resourceful 
                          Qualified 
                          Interactive 
                          Conscientious 
                            
                         
                      
 
                    
                       In your opinion, did the applicant fulfill all job requirements?  Please describe 
 
                    
                       What is one thing you feel the applicant could improve on? 
 
                    
                       On a scale of 1 – 10, how would you recommend the applicant for a nanny position? 
 
                    
                       In your own words, please give a detailed description of your experience with the applicant: 
 
                    
                       
                    
                      
							 
                     
                    
                       Thank you for your attention in this matter. ABC Nanny Source