ROCKDALE COUNTY PUBLIC SCHOOLS
HUMAN RESOURCES
P.O. BOX 1199
CONYERS, GEORGIA 30012-1199
770-860-4210
TEACHER APPLICANT REFERENCE CHECK FORM
(Name and Address of Reference)
___________________________________________
___________________________________________
___________________________________________
Dear: ______________________________________
I am applying with the Rockdale County Public Schools for a position as a(n)
____________________________ of _____________________________. Please complete the reference
statement on this form for me and return it directly to the Rockdale County Public Schools at the address
shown above, not to me.
I authorize you to release any and all information you may have concerning my past job performance or my
suitability for the position for which I am applying. I hereby release you and the Rockdale County Public
Schools from any and all liability which could result from the providing of the requested information or from its
use in the employee selection process. This reference is confidential and will not be shared with me.
Thank you for completing this form.
Sincerely,
___________________________________________
Name
____________________________________________
Address
____________________________________________
City
____________________________________________
State/Zip
Information given on the applicant is based on: (check all items which apply)
1. _____ Worked for me 2. _____ Co-Worker
3. _____ Personal Acquaintance 4. _____ Student in my class(es)
5. _____ Student teacher in my class 6. _____ Other _______________________________________
Have you observed this person teach? _____
___________________________________________________
NAME OF APPLICANT
Record in the box to the right of each item a number between 1 and 5 from the scale below to show how you
rate this applicant.
1. Outstanding (top 10%) 4. Below average (bottom 25%)
2. Above Average (top 25%) 5. Not observed
3. Average (Middle 50%)
Commitment to Profession: Classroom Management Skills-Ability To:
Maturity (poise, self-control) - assess pupil needs
Initiative - plan instructional experiences
Punctuality - evaluate pupil progress
Attendance - develop environment conducive to learning
Positive Attitude - relate well to pupils
Efficiency in routine matters (accuracy, etc.) - relate well to co-workers
Flexibility Communicates effectively with parents
Professional appearance Uses correct grammar while writing and speaking
Loyalty Maintains appropriate discipline
Overall rating
Check the appropriate blank following each question and write in or attach an explanation as needed.
Yes No
1. Has this applicant any moral, mental, emotional, or social peculiarities or
habits which would make him/her unsuitable as a teacher? _____ _____
2. Does the applicant accept extra duties willingly? _____ _____
3. Is this a person you would like to have teach your child or a child to whom
you are very close? _____ _____
4. With your present knowledge, would you employ this person in a school or
organization for which you are responsible? _____ _____
5. To your knowledge, has this person ever failed to have a contract renewed,
resigned to avoid being terminated, or been fired from employment? (If yes,
please explain.) _________________________________________________ _____ _____
6. Would you prefer talking by telephone about this person or his/her
performance record? _____ _____
_________________________________________________ _______________________________
Signature of Person Completing Form Date
__________________________________________________
Position/Title
__________________________________________________
Telephone Number
