VOLUNTEER RESOURCES & ENGAGEMENT - ________________
REFERENCE QUESTIONNAIRE
(This form is to be completed by two references)
Volunteer Name: ___________________________________________ Date: ____________________________
Please answer the questions regarding this prospective volunteer’s personality, character and qualities for
volunteering at __________________________. All information you share helps us find the right volunteer
placement for this person. The volunteer listed will be supporting staff and/or providing a social support to the
residents/patients and their loved ones at __________________________.
QUALITY
NOT
KNOWN
AVERAGE
BELOW
AVERAGE
ABOVE
AVERAGE
EXCELLENT
1. Reliability, commitment
2. Trustworthy, hones/Integrity
3. Ability to communicate and
be understood
4. Interpersonal skills, working
with others
5. Conflict resolution skills
6. Respectful/considerate
of others
7. Able to take direction
8. Good common sense
9. Good boundaries
10. Overall personality/character
PLEASE ANSWER THE FOLLOWING
YES
NO
COMMENTS
Is the applicant a suitable candidate?
Does the applicant require supervision?
Do you feel the applicant’s other commitments may interfere
with his/her commitment to volunteering?
Any further comments:
Reference Name: ________________________Relatio
nship to the applicant:___________________________
Phone or email:___________________________ Reference Signature:__________________________________
*
Please note an original signature is required unless this form is filled out online and sent from the referencespersonal email. The personal
email will be cons
idered a valid signature.
Please email, mail or drop off completed form to: Volunteer Resources & Engagement, Attention: RJH Intake
Email: ___________________________________________,
Mail/drop:________________________________________________________, _____________, BC, ________
Your reference is important and appreciated. Thank you.
RJHVolunteerIntake@VIHA.CA
Royal Jubilee Hospital, 1952 Bay St. Royal Block 453A
Victoria
V8R 1J8
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