Form 195 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the NAME OF APPLICANT at the top of the form. This identifies the individual for whom you are providing a reference.
3. In section 1, specify the applicant's current specialty. This helps contextualize their qualifications.
4. For section 2, input the date when the applicant began employment in their specialty using the format (mmyy).
5. In section 3, select one of the employment types: private practice/self-employed, employed full-time, part-time, or stipend employee. If applicable, provide average hours worked per week.
6. Sections 4a and 4b require descriptions of the healthcare facility size/type and work environment. Be detailed to give a clear picture of their professional setting.
7. In section 5, choose your relationship with the applicant and indicate your evaluation period. This establishes your credibility as a reference.
8. Provide your overall impression of the applicant in section 6 and answer whether you would hire or rehire them in section 7.
9. Rate each attribute listed in section 8 on a scale from 1 to 7 based on your assessment compared to peers.
10. Finally, complete your contact information at the bottom of the form including name, telephone number, signature, date, position/title/specialty, business address, and email address.

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