Leon County Schools Employment Reference

[Pages:2]Leon County Schools Employment Reference

Name of Applicant________________________________________________

Social Security Number____________________________________________

I authorize you to provide the Leon County School Board with information regarding my suitability for Employment. I further waive and release the Leon County School Board and the person or entity to whom this request is made of any and all claims or causes of action which I may take as a result of the full disclosure of any such employment information.

Name of Evaluator___________________________________________ (Please print/type)

Phone Number_______________________________________________

Title_______________________________________________________ (Please print/type)

School/Business______________________________________________

Signature of Applicant_____________________________________________

Position applying for______________________________________________

TO BE COMPLETED BY EVALUATOR The person named above has applied for a position with Leon County Schools and listed you as a reference. Please complete the sections below and return this reference form to the address listed below as quickly as possible

PROFESSIONAL /PERSONAL QUALITIES Attendance Record/Punctuality Verbal and Non-Verbal Communication Accuracy & Punctuality of Reports Attitude/Cooperation Enthusiasm Knowledge of Job/Ability to Learn Ability to Work With Others Quality of Work/Work Habits Initiative/Creativity Leadership Judgment/Common Sense TEACHER QUALITIES Classroom Organization and Control Effective Use of Methods and Techniques/Testing Planning and Preparation Competency In Academic Field Ability to Work With Other Teachers Interest and Enthusiasm Created For Pupils Ability to Work With Children

EXCELLENT

GOOD FAIR POOR

UNKNOWN

EXCELLENT

GOOD

FAIR POOR

UNKNOWN

PLEASE PROVIDE REQUESTED INFORMATION BELOW:

1. This evaluation covers the time period of from ____________through_____________

2. Is there any reason why this person should not be employed in a Public School System? Yes____________________ No________________________

3. If this person was a former employee, would you rehire? __________________________________________________________________________

4. Have you observed applicant teaching in a classroom situation? _____________________________________________________________________

5. I have known the applicant: __________as a student __________ as an employee

Other Remarks: ______________________________________________________________________________________________________________

Signature of Evaluator_________________________________________

Date______________________________________________

This form will be shown to the applicant or members of the public upon request, in compliance with Florida Statute 119, Public Records Law. Fax Correspondence is received at (850) 487-7822. Original must follow in mail. If you wish to discuss any part of this form, call toll free 1-800245-9449 between 8:00a.m.-5:00p.m. EST and ask for Personnel Services.

Return this form to: Personnel Services Section 2757 West Pensacola Street Tallahassee, Florida 32304-2998

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Collection of Social Security Numbers Per Florida Statute 119.071(5), this is to notify you of the purpose for collecting and utilizing your social security number. Providing your social security number is a condition of employment at Leon County Public Schools. To protect your identification, we will secure your social security number from unauthorized access, and strictly prohibit the release of your social security number to unauthorized parties contrary to state and federal law. Leon County Public Schools collects your social security number for legitimate business purposes during the recruitment, selection and hiring process. Once you are employed, your social security number will be used for completing State and Federal mandated reports and actions that require such, including but not limited to the following:

Cost reporting [237.34 F.S.], Employment application for determining certification eligibility [1012.56 F.S.], Completion of Federal I-9 form for the filing and issuance of Federal employment forms [8 USC 1324a(b)], Completion of Federal W-4 form for filing and issuance of Federal employment forms [8 USC 1324a(b)], Florida Retirement Contribution Report [119.071(5)(a)6.b.], Conducting criminal background screening [1012.56 F.S.].

The procedures for the security, privacy and retention of automated student and staff records shall be in accordance with the requirements of U.S.C 1232g(b)(3), 34 C.F.R.

Part 99 and Section 1002.22.F.S.

P:\PRSNNL\WORK\FORMS\PATS\LCS Reference Form Revised 10-21-2011.docx

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