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Employer Reference

By completing this Reference Form you acknowledge and understand that: Reference checks are conducted with the understanding that the information gathered remains confidential, in so far as the law allows. The information collected during a reference check belongs to the individual being considered for a position into the program. It shall only be released to them by a written request through FOIPOP. 

This form must be completed by the applicant’s manager. The assessment constitutes one part of the registration process. 


First Name of Referent:


Last Name of Referent:


Job Title:


Work Mailing Address:




Contact Phone #:


First Name of Applicant:


Last Name of Applicant:


Please enter the cost center from which course fees will be paid:


Name of Program:

Practice Preceptor Name:


Study Option:

Full-time/Part-time Accelerated Part Time Full Time Regular Part Time Other

Please comment on the applicant’s ability in the following areas:



Clinical decision making;
competence in practice: 

Professional Behavior:

Leadership Skills:

General Comments:

This online form transmits the required information to the associated Program Faculty and is automatically stored within our registration database. This decreases any inconveniences associated with misplaced faxes and also protects the confidentiality and privacy of the registrant. Please inform us at rnpdc@nshealth.ca  if it is not possible for the employer to complete using this preferred method.