Survey - Volunteer Family Assistance Program Reference Check

Volunteer Family Assistance Program Reference Check

Thank you for taking time to complete this reference check for The ALS Association Iowa Chapter's Volunteer Family Assistance Program.
This reference check is part of the screening process our chapter uses to ensure the safety of the people with ALS and to help them feel comfortable with a volunteer serving in their home.

*1.	Question - Required - Your Name:
*2.	Question - Required - Name of person for whom you are completing this reference check:
*3.	Question - Required - How long have you known the applicant and in what capacity/relationship?
*4.	Question - Required - How is the applicant's ability to keep scheduled appointments? Excellent Good Fair Poor Unknown
*5.	Question - Required - How is the applicant's ability to follow policies and procedures? Excellent Good Fair Poor Unknown
*6.	Question - Required - How are the applicant's communication skills? Excellent Good Fair Poor Unknown
*7.	Question - Required - How well does the applicant handle feedback and constructive criticism? Very Well Well Fairly Well Poorly Unknown
*8.	Question - Required - How well do you think the applicant will work with a person who has a disability? Very Well Well Fairly Well Poorly Unknown
*9.	Question - Required - As ALS progresses, people experience muscle weakness and paralysis meaning they are unable to care for themselves and protect themselves from harm. Do you have any reservations about the applicant working directly with or in the home of someone who may be a vulnerable adult? Yes No Unsure
10.	Question - Not Required - If you answered Yes or Unsure on the previous question, why?
11.	Question - Not Required - Is there anything else you'd like to share?