Page 1 of 3
EVERETT PUBLIC SCHOOLS
REFERENCE FORM FOR ADMINISTRATIVE POSITIONS
NOTE TO APPLICANT: Please complete Section 1 and then forward to your current and/or past supervisor(s).
SECTION 1 – TO BE COMPLETED BY APPLICANT
I, _________________________________________, am an applicant with the Everett Public Schools for an administrative position.
Please state frankly your opinion of my abilities on the form below. Thank you for your assistance.
I hereby authorize Everett Public Schools to conduct reference checks to obtain information relating to my application of employment
with no liability arising therefrom. I am advised that the reference checks may include information on my character, general
reputation and personal characteristics as they may relate to my ability to perform the job for which I am applying.
__________________________________________________
___________________________________________
Signature of Applicant
Social Security Number
(Optional)
SECTION 2 – TO BE COMPLETED BY CURRENT AND/OR PAST SUPERVISOR
______________________________________
______________________________
____________________________
Print name of person completing reference
Title
Telephone Number
_________________________________________________________________________
____________________________
Working relationship with applicant
How long?
_________________________________________________________________________
____________________________
Signature of person completing reference
Date
INSTRUCTIONS
: Please complete the following form to the best of your ability. A rating of 9 on the 1-10 scale indicates that the
applicant is at the 90th percentile (upper 10%); a rating of 1 places the applicant at the 10th percentile (lower 10%); a rating of 5
places the applicant at the 50th percentile (about the middle), etc. Any specific comments that will support your rating will be
appreciated. Please neatly circle the appropriate response.
PERSONAL:
1.
Adapts to new situations readily.
Never 1 2 3 4 5 6 7 8 9 10 Always
2.
Never 1 2 3 4 5 6 7 8 9 10 Always
Projects a relaxed and confident manner when leading or working in
front of a group of peers, parents or other adults.
3.
Accepts criticism as information that will help in planning self-
improvement. Is not easily shaken by complaints of others.
Never 1 2 3 4 5 6 7 8 9 10 Always
4.
Constantly seeks ways to improve own professional skills.
Never 1 2 3 4 5 6 7 8 9 10 Always
LEADERSHIP:
5.
Assumes responsibility willingly and carries out tasks efficiently.
Never 1 2 3 4 5 6 7 8 9 10 Always
6.
Shows competence in planning, scheduling and managing details.
Never 1 2 3 4 5 6 7 8 9 10 Always
7.
Participates freely in group discussions of professional problems.
Never 1 2 3 4 5 6 7 8 9 10 Always
8.
Demonstrates ability to make decisions and to be responsible for those
decisions.
Never 1 2 3 4 5 6 7 8 9 10 Always
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9.
Shows ability to diagnose problems and gather the support of others in
solving the problem.
Never 1 2 3 4 5 6 7 8 9 10 Always
10. Demonstrates persistence in working toward clear goals.
Never 1 2 3 4 5 6 7 8 9 10 Always
11. Demonstrates flexibility in using a variety of leadership styles in
appropriate situations.
Never 1 2 3 4 5 6 7 8 9 10 Always
12. Promotes creativity among staff.
Never 1 2 3 4 5 6 7 8 9 10 Always
13. Is well organized.
Never 1 2 3 4 5 6 7 8 9 10 Always
14. Is a good self-starter and manager.
Never 1 2 3 4 5 6 7 8 9 10 Always
CURRICULUM AND INSTRUCTION:
(If applicable)
15. Participates in curriculum improvement projects.
Never 1 2 3 4 5 6 7 8 9 10 Always
16. Assists staff in developing specific strategies for objectives.
Never 1 2 3 4 5 6 7 8 9 10 Always
17. Sets high expectations for students and staff performance.
Never 1 2 3 4 5 6 7 8 9 10 Always
18. Demonstrates ability to plan, implement and evaluate effective
educational programs.
Never 1 2 3 4 5 6 7 8 9 10 Always
19. Demonstrates awareness of need for instructional improvement. Is not
satisfied with “the way things are.”
Never 1 2 3 4 5 6 7 8 9 10 Always
20. Possesses the understanding and commitment to providing alternative
programs and options appropriate to students with special needs.
Never 1 2 3 4 5 6 7 8 9 10 Always
COMMUNICATION:
21. Shows ability to communicate using clear verbal illustrations and
explanations.
Never 1 2 3 4 5 6 7 8 9 10 Always
22. Shows ability to write clearly and transmit ideas effectively on paper.
Never 1 2 3 4 5 6 7 8 9 10 Always
23. Facilitates open communication and understanding between school,
staff, central office and support staff.
Never 1 2 3 4 5 6 7 8 9 10 Always
HUMAN RELATIONS:
24. Builds student self-esteem and is courteous in working with children.
Never 1 2 3 4 5 6 7 8 9 10 Always
25. Organizes the school to reflect team planning and decision making.
Never 1 2 3 4 5 6 7 8 9 10 Always
26. Develops a sense of unity and common purpose among the staff.
Never 1 2 3 4 5 6 7 8 9 10 Always
27. Displays loyalty to the best interests of the school and the school
district.
Never 1 2 3 4 5 6 7 8 9 10 Always
28. Has demonstrated an ability to work cooperatively and productively
with others.
Never 1 2 3 4 5 6 7 8 9 10 Always
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29. Is skilled in interpersonal relation techniques.
Never 1 2 3 4 5 6 7 8 9 10 Always
30. Manages conflict productively and resolves problems effectively with
parents, students and / or staff.
Never 1 2 3 4 5 6 7 8 9 10 Always
31. Involves others in policy and goal setting.
Never 1 2 3 4 5 6 7 8 9 10 Always
32. Identifies resources for programs.
Never 1 2 3 4 5 6 7 8 9 10 Always
33. Promotes community awareness and support for programs.
Never 1 2 3 4 5 6 7 8 9 10 Always
34. Maintains relationships characterized by a high degree of trust, support
and recognition.
Never 1 2 3 4 5 6 7 8 9 10 Always
35. Allows others to influence policies where appropriate.
Never 1 2 3 4 5 6 7 8 9 10 Always
36. Maintains a friendly environment.
Never 1 2 3 4 5 6 7 8 9 10 Always
STUDENT DISCIPLINE:
(If applicable)
37. Uses effective strategies in changing student behavior.
Never 1 2 3 4 5 6 7 8 9 10 Always
38. Demonstrates ability to interact effectively with students of various
ethnic and racial backgrounds.
Never 1 2 3 4 5 6 7 8 9 10 Always
OVERALL IMPRESSION:
39. Overall impression of the applicant’s qualifications as a potential
candidate for this position.
123 4 5 6 7 8910
COMMENTS:
Please return this Form by mail or by fax to the Human Resources Department.
Executive Director of Human Resources
Everett Public Schools, Human Resources Department
3715 Oakes Avenue
Everett, WA 98201
Telephone: (425) 385-4100
Fax: (425) 385-4102
Revised: 1/12/06