999 Our St.,
This Town, BC
X1X 1X1
21 September 2009
Mr. Smith
123 Any St..
This Town, BC
Z1Z 1Z1
Dear Bob,
Re: Q, Suzie - Reference
I am contacting you in regards to Suzie Q as she has given your name as a reference. It is the responsibility of the ABC Society to find trustworthy, safe, non-judgmental, caring volunteers to do Hospice work. We have a screening process to ensure we find appropriate volunteers to help patients and their families deal with life threatening and terminal illness. The role of a Hospice volunteer can involve working in the Hospice house, hospital, long-term care facility, or in the client’s home. Could we please have a few moments of your time to provide responses to the following questions? We appreciate your full and honest information. All information is kept strictly confidential.
If possible, please return this questionnaire by: 09 October 2009
1. How long have you known Suzie ? ______
2. In what capacity do you know her? ______
3. Do you consider Suzie to be open-minded, non-judgmental, non-racist, and accepting of alternative lifestyles and cultures? Yes _____ No _____
Comment:
______
4. Do you consider Suzie to be a caring individual who supports her friends and/or co-workers?
Yes ____ No ______
Comment:
______
5. Would you confide in Suzie ? Yes _____ No ______
Comment:
______
6. Do you consider Suzie to be a good listener? Yes _____ No _____
Comment:
______
7. Has Suzie ever given you unsolicited advice? Yes ___ No ___
Comment:
______
8. How would you describe Suzie’s personality and temperament?
______
______
9. To the best of your knowledge, does Suzie follow through on her commitments? Yes __No__
Comment:
______
10. What do you believe Suzie’s greatest strengths to be?
______
11. What do you consider an area of challenge or weakness for Suzie?
______
12. Would you be willing to have Suzie work on a one-on-one basis with a member of your family if they were suffering from a life-threatening illness? Yes ____ No ____
Comment:
______
13. Is there anything else you would like to add?
______
14. Would you recommend Suzie as a volunteer for the ABC Society?
Yes ____ No ____
Thank you for your time and honesty. Please return this form in the enclosed self-addressed envelope.
Sincerely
My Name
Volunteer Resources
ABC Society