NHUVA Junior Volunteer Reference Form

Novant Health UVA Health System

Junior Volunteer Evaluator Recommendation Form

Participation in the Junior Volunteer Program requires a high level of maturity, responsibility, and committment. Applicants are accepted based on their application, recommendations, and interview. Please take the time to honestly evaluate this applicant by filling out the form below. We appreciate your insights, and your responses will remain confidential.

Today's Date *

Junior Volunteer Applicant:

Name *

Evaluator:

Evaluator *

Email Address *

Best Phone Number *

Relationship to applicant (Please list subject taught, if you are a teacher) *

How long have you known this applicant? *

Performance

Please rank this applicant using the following criteria: *

	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant displays conduct appropriate to a setting.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant works well with peers and adults.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant completes assigned tasks.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant accepts responsibility for assigned tasks and personal behavior.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant listens and follows instructions.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant demonstrates effective oral communication.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant is resourceful and self-reliant with new situations.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant demonstrates respect for others, accepts supervision, and treats others with kindness.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant acts appropriately in a given situation.	Always	Usually	Frequently	Rarely	No Opportunity to Observe
Applicant is punctual.	Always	Usually	Frequently	Rarely	No Opportunity to Observe

If you were a patient or employee at a hospital, would you like this applicant assigned to your area? If no, please explain. *

To your knowledge, has this applicant been subjected to any disciplinary action? If yes, please explain. *

What distinguishes this applicant from others? *

Please provide any additional information that may be relevant to this evaluation. *

Evaluator: Once you answer the final question below, you will receive an automatic reply email with a copy of your responses. Please check your email to ensure that we have received your reference. If it does not come to your regular inbox please check your SPAM folder. Thank you for taking the time to complete this questionaire, your input is sincerely appreciated!

I certify that I am the evaluator listed above *

If you have any questions, please contact:

Jude Kelly, Volunteer Programs Coordinator

Novant Health UVA Health System Prince William Medical Center

jgkelly@novanthealth.org * 703-369-8173

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