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https://nomadhealth.com/reference/62753c92d96efe74a533df1e/?utm_source=sendgrid&utm_medium=email&supervisor=yes
Submission: On May 06 via manual from US — Scanned from DE
Submission: On May 06 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form aria-label="nurse reference form">
<div class="row">
<div id="reference-title" class="col-md-12">
<section class="form-section">
<h2 class="form-section-title">Employment Confirmation</h2>
<div class="toggle-accordion-container">
<div class="toggle-accordion-header"><span class="toggle-accordion-question required-asterisk">If you had the ability, would you rehire Nolana Foster based on their performance?</span>
<div class="form-group css-0">
<div id="wouldRehire" class="radio-toggles radio-toggles--binary"><label class="radio-inline radio-toggle"><input name="wouldRehire" type="radio" value="false"><span class="radio-toggle-text">No</span></label><label
class="radio-inline radio-toggle"><input name="wouldRehire" type="radio" value="true"><span class="radio-toggle-text">Yes</span></label></div>
</div>
</div>
</div>
</section>
<div class="form-group css-0">
<div class="label-wrapper css-0"><label class="required-asterisk css-0" for="professionalTitle">
<p class="MuiTypography-root reference-required-asterisk css-0 MuiTypography-body2">Your highest title held during this time</p>
<h6 class="MuiTypography-root MuiTypography-h6 MuiTypography-colorTextSecondary">Please keep in mind that some jobs that nurse name has applied to may require references that are more supervisory than Charge RN. If you held a title higher
than Charge RN while working with nurse name, please provide this title.</h6>
</label></div>
<div name="professionalTitle" value="">
<div class="flat-select-wrapper full-width"><label class="flat-select-label"><select id="professionalTitle" class="flat-select form-control">
<option value="" selected="">Select one</option>
<option value="ADON">ADON</option>
<option value="APRN">APRN</option>
<option value="Assistant Clinical Leader">Assistant Clinical Leader</option>
<option value="Assistant Director of Nursing">Assistant Director of Nursing</option>
<option value="Assistant Nurse Manager">Assistant Nurse Manager</option>
<option value="Assistant Unit Manager">Assistant Unit Manager</option>
<option value="Associate Nurse Manager">Associate Nurse Manager</option>
<option value="Charge RN">Charge RN</option>
<option value="Chief Nursing Officer">Chief Nursing Officer</option>
<option value="Clinic Manager">Clinic Manager</option>
<option value="Director of Clinical Services">Director of Clinical Services</option>
<option value="Director of Clinical Unit">Director of Clinical Unit</option>
<option value="Director of Nursing">Director of Nursing</option>
<option value="Director of Surgical Services">Director of Surgical Services</option>
<option value="DON">DON</option>
<option value="Facility Floor Supervisor">Facility Floor Supervisor</option>
<option value="Floor Manager or Floor Supervisor">Floor Manager or Floor Supervisor</option>
<option value="House Supervisor">House Supervisor</option>
<option value="Lead Clinician">Lead Clinician</option>
<option value="Lead Nurse">Lead Nurse</option>
<option value="Manager">Manager</option>
<option value="MD">MD</option>
<option value="Nurse Leader">Nurse Leader</option>
<option value="Nursing Manager">Nursing Manager</option>
<option value="NP">NP</option>
<option value="Other">Other</option>
<option value="PA">PA</option>
<option value="RN Manager">RN Manager</option>
<option value="RN Supervisor">RN Supervisor</option>
<option value="Shift Supervisor">Shift Supervisor</option>
<option value="Supervisor">Supervisor</option>
</select><span class="flat-select-label-decoration">Select one</span></label></div>
</div>
</div>
<section class="form-section">
<h2 class="form-section-title">Performance and Attributes</h2>
<div class="radio-toggles-container"><label for="formAnswer1" class="form-answer-label">Provides competent clinical care following facility policies and procedures:</label>
<div class="form-group active-toggle reference-form-group css-0">
<div id="formAnswer1" class="radio-toggles reference-toggles"><label class="radio-inline radio-toggle"><input name="formAnswer1" type="radio" value="n/a"><span class="radio-toggle-text">N/A</span></label><label
class="radio-inline radio-toggle"><input name="formAnswer1" type="radio" value="below standard"><span class="radio-toggle-text">Below Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer1"
type="radio" value="meets standard"><span class="radio-toggle-text">Meets Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer1" type="radio" value="above standard"><span
class="radio-toggle-text">Above Standard</span></label></div>
</div>
</div>
<div class="radio-toggles-container"><label for="formAnswer2" class="form-answer-label">Communicates effectively with patients, families, and staff:</label>
<div class="form-group active-toggle reference-form-group css-0">
<div id="formAnswer2" class="radio-toggles reference-toggles"><label class="radio-inline radio-toggle"><input name="formAnswer2" type="radio" value="n/a"><span class="radio-toggle-text">N/A</span></label><label
class="radio-inline radio-toggle"><input name="formAnswer2" type="radio" value="below standard"><span class="radio-toggle-text">Below Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer2"
type="radio" value="meets standard"><span class="radio-toggle-text">Meets Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer2" type="radio" value="above standard"><span
class="radio-toggle-text">Above Standard</span></label></div>
</div>
</div>
<div class="radio-toggles-container"><label for="formAnswer3" class="form-answer-label">Completes accurate documentation of patient care:</label>
<div class="form-group active-toggle reference-form-group css-0">
<div id="formAnswer3" class="radio-toggles reference-toggles"><label class="radio-inline radio-toggle"><input name="formAnswer3" type="radio" value="n/a"><span class="radio-toggle-text">N/A</span></label><label
class="radio-inline radio-toggle"><input name="formAnswer3" type="radio" value="below standard"><span class="radio-toggle-text">Below Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer3"
type="radio" value="meets standard"><span class="radio-toggle-text">Meets Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer3" type="radio" value="above standard"><span
class="radio-toggle-text">Above Standard</span></label></div>
</div>
</div>
<div class="radio-toggles-container"><label for="formAnswer4" class="form-answer-label">Ability to communicate with staff:</label>
<div class="form-group active-toggle reference-form-group css-0">
<div id="formAnswer4" class="radio-toggles reference-toggles"><label class="radio-inline radio-toggle"><input name="formAnswer4" type="radio" value="n/a"><span class="radio-toggle-text">N/A</span></label><label
class="radio-inline radio-toggle"><input name="formAnswer4" type="radio" value="below standard"><span class="radio-toggle-text">Below Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer4"
type="radio" value="meets standard"><span class="radio-toggle-text">Meets Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer4" type="radio" value="above standard"><span
class="radio-toggle-text">Above Standard</span></label></div>
</div>
</div>
<div class="radio-toggles-container"><label for="formAnswer5" class="form-answer-label">Attendance and punctuality:</label>
<div class="form-group active-toggle reference-form-group css-0">
<div id="formAnswer5" class="radio-toggles reference-toggles"><label class="radio-inline radio-toggle"><input name="formAnswer5" type="radio" value="n/a"><span class="radio-toggle-text">N/A</span></label><label
class="radio-inline radio-toggle"><input name="formAnswer5" type="radio" value="below standard"><span class="radio-toggle-text">Below Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer5"
type="radio" value="meets standard"><span class="radio-toggle-text">Meets Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer5" type="radio" value="above standard"><span
class="radio-toggle-text">Above Standard</span></label></div>
</div>
</div>
<div class="radio-toggles-container"><label for="formAnswer6" class="form-answer-label">Flexibility and adaptability:</label>
<div class="form-group active-toggle reference-form-group css-0">
<div id="formAnswer6" class="radio-toggles reference-toggles"><label class="radio-inline radio-toggle"><input name="formAnswer6" type="radio" value="n/a"><span class="radio-toggle-text">N/A</span></label><label
class="radio-inline radio-toggle"><input name="formAnswer6" type="radio" value="below standard"><span class="radio-toggle-text">Below Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer6"
type="radio" value="meets standard"><span class="radio-toggle-text">Meets Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer6" type="radio" value="above standard"><span
class="radio-toggle-text">Above Standard</span></label></div>
</div>
</div>
<div class="radio-toggles-container"><label for="formAnswer7" class="form-answer-label">Overall professionalism:</label>
<div class="form-group active-toggle reference-form-group css-0">
<div id="formAnswer7" class="radio-toggles reference-toggles"><label class="radio-inline radio-toggle"><input name="formAnswer7" type="radio" value="n/a"><span class="radio-toggle-text">N/A</span></label><label
class="radio-inline radio-toggle"><input name="formAnswer7" type="radio" value="below standard"><span class="radio-toggle-text">Below Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer7"
type="radio" value="meets standard"><span class="radio-toggle-text">Meets Standard</span></label><label class="radio-inline radio-toggle"><input name="formAnswer7" type="radio" value="above standard"><span
class="radio-toggle-text">Above Standard</span></label></div>
</div>
</div>
</section>
<section class="form-section">
<h2 class="form-section-title">Contact Preference</h2>
<div class="row">
<div class="col-md-12">
<div class="form-group css-0">
<div class="label-wrapper css-0"><label class=" css-0" for="otherContactInfo">If +1 602-881-8444 and tcalabrese@honorhealth.com are not the correct phone number and email for contacting you please let us know the preferred method of
contact. If there are any other notes we need to know about contacting you (extension, best time to contact, etc) please provide below.</label></div><textarea name="otherContactInfo" class="form-control"
id="otherContactInfo"></textarea>
</div>
</div>
</div>
</section>
<section class="form-section">
<h2 class="form-section-title">Additional Comments</h2>
<div class="row">
<div class="col-md-12">
<div class="form-group css-0">
<div class="label-wrapper css-0"><label class=" css-0" for="additionalComments">Anything else to share?</label></div><textarea name="additionalComments" class="form-control" id="additionalComments"></textarea>
</div>
</div>
</div>
</section>
</div>
</div>
<div class="reference-form-button row">
<div class="col-md-12">
<div class="form-group css-0">
<div class="label-wrapper css-0"><label class=" css-0" for="identityVerified"></label></div><label class="checkbox-inline"><input name="identityVerified" type="checkbox" value=""><span class="checkbox-inline-text">I certify that I am Tracy
calabrese and all information provided about my relationship with Nolana Foster is true. I understand that Nolana Foster and I will be suspended from Nomad Health if the information provided is not accurate.</span></label>
</div>
</div>
<div class="col-md-6">
<div class="form-group css-0">
<div class="label-wrapper css-0"><label class="required-asterisk css-0" for="referenceSignature">Signature</label></div><input name="referenceSignature" class="form-control" id="referenceSignature" type="text" value="">
</div>
</div>
<div class="col-md-4">
<div class="form-group css-0">
<div class="label-wrapper css-0"><label class=" css-0">Signature Date</label></div><input disabled="" class="form-control" type="text" value="5/6/2022">
</div>
</div>
<div class="col-md-2">
<div class="pb-container disabled pb-btn pb-btn-primary"><button class="pb-button" disabled=""><span>Submit</span><svg class="pb-progress-circle" viewBox="0 0 41 41">
<path d="M38,20.5 C38,30.1685093 30.1685093,38 20.5,38"></path>
</svg><svg class="pb-checkmark" viewBox="0 0 70 70">
<path d="m31.5,46.5l15.3,-23.2"></path>
<path d="m31.5,46.5l-8.5,-7.1"></path>
</svg><svg class="pb-cross" viewBox="0 0 70 70">
<path d="m35,35l-9.3,-9.3"></path>
<path d="m35,35l9.3,9.3"></path>
<path d="m35,35l-9.3,9.3"></path>
<path d="m35,35l9.3,-9.3"></path>
</svg></button></div>
</div>
</div>
</form>Text Content
⚠ Your browser is not supported. Please update for the best Nomad experience. Toggle navigation Register * About * For nurses * For employers * Sign in * Register COMPLETE REFERENCE FORM Please rate Nolana Foster’s clinical performance and attributes below 888. These responses are confidential and will only be shared with the hiring manager. Nolana Foster will not see your responses. EMPLOYMENT CONFIRMATION If you had the ability, would you rehire Nolana Foster based on their performance? NoYes Your highest title held during this time PLEASE KEEP IN MIND THAT SOME JOBS THAT NURSE NAME HAS APPLIED TO MAY REQUIRE REFERENCES THAT ARE MORE SUPERVISORY THAN CHARGE RN. IF YOU HELD A TITLE HIGHER THAN CHARGE RN WHILE WORKING WITH NURSE NAME, PLEASE PROVIDE THIS TITLE. Select oneADONAPRNAssistant Clinical LeaderAssistant Director of NursingAssistant Nurse ManagerAssistant Unit ManagerAssociate Nurse ManagerCharge RNChief Nursing OfficerClinic ManagerDirector of Clinical ServicesDirector of Clinical UnitDirector of NursingDirector of Surgical ServicesDONFacility Floor SupervisorFloor Manager or Floor SupervisorHouse SupervisorLead ClinicianLead NurseManagerMDNurse LeaderNursing ManagerNPOtherPARN ManagerRN SupervisorShift SupervisorSupervisorSelect one PERFORMANCE AND ATTRIBUTES Provides competent clinical care following facility policies and procedures: N/ABelow StandardMeets StandardAbove Standard Communicates effectively with patients, families, and staff: N/ABelow StandardMeets StandardAbove Standard Completes accurate documentation of patient care: N/ABelow StandardMeets StandardAbove Standard Ability to communicate with staff: N/ABelow StandardMeets StandardAbove Standard Attendance and punctuality: N/ABelow StandardMeets StandardAbove Standard Flexibility and adaptability: N/ABelow StandardMeets StandardAbove Standard Overall professionalism: N/ABelow StandardMeets StandardAbove Standard CONTACT PREFERENCE If +1 602-881-8444 and tcalabrese@honorhealth.com are not the correct phone number and email for contacting you please let us know the preferred method of contact. If there are any other notes we need to know about contacting you (extension, best time to contact, etc) please provide below. ADDITIONAL COMMENTS Anything else to share? I certify that I am Tracy calabrese and all information provided about my relationship with Nolana Foster is true. I understand that Nolana Foster and I will be suspended from Nomad Health if the information provided is not accurate. Signature Signature Date Submit NOLANA FOSTER, R.N. COMPANY * About * Careers * Contact us SOLUTIONS * For nurses * For other clinicians * For employers RESOURCES * FAQ * Press * Blog YOUR ACCOUNT * Register * Sign in © 2022 Nomad Health Privacy Policy Terms & Conditions