Giving a Reference for an Applicant

Fill out and submit this form after Big Brothers Big Sisters contacts you requesting that you provide a reference for a person you know who has applied to become a Big. This form consists of 20 questions.

About You

Your Name
Your Email

About the Applicant

Applicant's Name
Applicant's Contact		(If known. This is the person the applicant is working with at Big Brothers Big Sisters.)

Your Feedback Regarding the Applicant

	1.	How long have you known the applicant?
	2.	What is your primary relationship with the applicant?		Friend Parent Teacher Counselor Coworker Neighbor Supervisor Other	If "Other" please explain:
	3.	How well do you know the applicant?		Very Well Well Average Little Very Little
	4.	If the applicant is your student, how effectively is the student maximizing his or her academic performance?		Not Applicable Excellent Above Average Average Below Average Well Below Average Varying Unkown
	5.	How would you describe the applicant's relationship with adults? (For multiple responses, press Ctrl while clicking on each option.)		Warm Shallow Loyal Shy Respectful Friendly Sincere Distant Other	If "Other" please explain:
	6.	How would you describe the applicant's relationship with youth in general (peers, siblings, etc.)? (For multiple responses, press Ctrl while clicking on each option.)		Impatient Distant Understanding Stern Well-liked Patient Friendly Warm Don't Know Other	If "Other" please explain:
	7.	How would you describe the applicant's capacity for friendship? (For multiple responses, press Ctrl while clicking on each option.)		Impatient Well-Liked Friendly Distant Patient Understanding Stern Sincere Cold Warm Shallow Loyal Shy Unknown
	8.	How would you describe the applicant's friendships? (For multiple responses, press Ctrl while clicking on each option.)		Many Friends Several Friends Few Friends Loyal Friends No Friends Unknown
	9.	How would you describe the applicant's ability to be flexible?		Excellent Good Average Fair Poor
	10.	Choose all that apply in describing the applicant. (For multiple responses, press Ctrl while clicking on each option.)		Leader Impulsive Domineering Nervous Indecisive Friendly Dependable Happy Procrastinator Open-Minded Stable Immature Selfish Calm Patient Impatient Sensitive Assertive Rigid Cooperative Liberal Lacks Confidence Aggressive Follower Opinionated Confident Egotistical Well-Adjusted Unhappy Worrier Temperamental Independent Conservative
	11.	Choose all that apply in describing the applicant's temperament: (For multiple responses, press Ctrl while clicking on each option.)		Hot-Tempered Patient Varying Stable Easily Upset Impatient Tends To Be Violent Unkown
	12.	To what extent is the applicant aware of his or her own shortcomings?		Feel They Have None Ignores Them Adjusts For Them Lacks Sight Realizes Them With No Adjustment Unkown
	13.	How would you describe the applicant's general health? (For multiple responses, press Ctrl while clicking on each option.)		Good Health Habits Habits Need Improvement Manages Stress Well Does Not Manage Stress Well
	14.	Check the appropriate box and explain if you feel applicant experiences any of the following.		Physical limitation(s)—If checked, please explain: Emotional problem(s)—If checked, explain:
	15.	How does the applicant assume responsibility?		Excellent Good Average Fair Poor
	16.	How do does the applicant manages his or her time?		Excellent Good Average Fair Poor
	17.	Do you feel the applicant has the organizational skills needed to follow-through with the commitment of once a week for one hour for the length of the program commitment? Choose one response and explain.		To The Best Of Your Knowledge Possible Complications Foreseen Explanation:
	18.	Would you be comfortable having the volunteer applicant help your child or a child in your family?		Yes No
	19.	Do you know of any reason why the applicant would not serve well as a volunteer?
	20.	If you have any additional information that you feel would be helpful to us please note it here.

If you would like to discuss any information please feel free to call us at (515) 288-9025.