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ConnectWell – Reference check for Prospective Board and Committee Members

Date Submitted(Required)

Name of referee(Required)

First Last

Phone(Required)

Name of Applicant(Required)

First Last

1. What is your relationship to the applicant? How long have you known the applicant and in what capacity?(Required)

2. Working effectively on a Board requires many skills and abilities, including an ability to: understand and analyze information from a variety of sources and perspectives, to work constructively with conflict, to respect diverse opinions, lifestyles, and beliefs, to maintain the highest level of confidentiality, and to respect the different roles and responsibilities between Operations and Governance. In light of this, and with your knowledge of the applicant, could you please comment on:

i) the specific skills and knowledge they would bring to the Board(Required)

ii) how you feel their beliefs and values would be aligned with those of ConnectWell Community Health(Required)

iii) how they work with interpersonal conflict or a conflict of ideas or approaches?(Required)

iv) How you feel they would respect the different roles and responsibilities between Operations and Governance.(Required)

3. Can you comment on any areas of concern you have that might make them unable to successfully fulfill this role?(Required)

4. Is there anything else the Nominating Committee should be aware of as we make our recommendation? Is there anything else you would like to add?

If any clarification is needed regarding this reference, may we contact you?(Required)

Yes

ConnectWell – Reference check for Prospective Board and Committee Members

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