Reference Evaluation Form

Check Box B

Please Check ALL Certifications That Applicant Is Applying For

 

CHSP CHSP-FSM  CHCM   CPSO    

 

CHEP  CHEP-FSM  CPSM 

  

Name Of Applicant  :

Name Of Reference:

 

Please Fill Out Entire Form

1. I have known the applicant since (Month and Year)

 

2. Briefly explain the circumstances under which you formed 

your judgment of the applicant’s capabilities.

 

3.  If your relationship/association with the applicant had a bearing on his or her job or task responsibilities, briefly describe how the applicant performed.

 

4. List any applicant achievements or accomplishments in the area in which he or she is seeking certification.

 

5. Personal Apprasial Ratings:

 

From your personal knowledge/observation of the applicant, select a description that best expresses your appraisal in each area.  Use the following key:               

 

0 = Not Observed        1 = Excellent 2 = Satisfactory                 3 = Poor 

Skills/Abilities

Rating

1. Decision Making

2. Oral Expression

3. Writing Skills

4. Supervisory Effectiveness

5. Problem Solving

6. Job Initiative/Innovation

7. Working Relationships

8. Leadership

9. Teamwork

10. Use of Management Techniques

11. Application of Codes/Standards

12. Inspection/Observation Ability

13. Technical/Professional Knowledge

 

 

6. As applicable, make any comments on your appraisal 

ratings in the space below.

 

 

7. Are there any reasons why you would not recommend 

the applicant for certification? (Yes/No)

 

(If Yes Explain Below)

 

 

8. Evaluator Information:

 
Name/Title:: 
Organization::
Address:
City/State/Zip:
Phone:
Email:
Digital Signature:

 

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