Information Service

Distribution: Background Investigations Unit

Central Screening Unit

Respondent

Printed on Recycled Paper

DOC 0037 (Rev. 3/2017)

EMPLOYMENT REFERENCE CHECK

To:

Information Requested for:

(Print Applicant’s Name)

(Social Security Number) (Date)

I hereby authorize you to answer all applicable questions appearing on this form.

(Signature of Applicant)

The applicant’s written consent for release of information is on file at the Department; no signature is required herein. The individual listed above has applied for employment at a correctional facility for the Illinois Department of Corrections (IDOC) or a contractual company that provides a service to IDOC. Please complete the following applicable data and return this form to the address or email listed below. Please attach additional pages if necessary. This information will be considered highly confidential. IDOC – Central Screening Office Email: ***.************@***.********.*** 1301 Concordia Court, P.O. Box 19277 Phone: 217-***-**** Springfield, IL 62794-9277 Fax: 217-***-****

Your prompt attention to this request will assist in preventing undue delays in the hiring process. How long have you known this applicant? Employed from: / / to / / Outstanding characteristics:

Do you know of any reason why this applicant should not be employed by or at a correctional facility? No Yes, please explain:

Quality and quantity of work: Excellent Good Average Less than average Poor Describe the applicant’s work attendance:

List all job titles held by the applicant, with most recent title first:

# of Staff

Title From To Supervised

/ / / /

/ / / /

/ / / /

On what basis did the applicant leave your employ? Resigned Laid Off Discharged Other Would you re-employ the applicant? Yes No, reason: Completed By:

(Please print name of person completing form)

Contact this candidate