Volunteer Reference Questionnaire : Become a CASA : CASA of San Bernardino County

Volunteer Reference Questionnaire

Someone you know has applied as a volunteer for our program and has given your name as a reference. Court Appointed Special Advocates (CASA’s), advocate for the rights of children who are in the child welfare system, serve as the voice of the children in juvenile court dependency proceedings, and reduce the trauma to children in the juvenile court dependency system by providing a long-term, consistent and stable relationship with them. Your response is completely confidential and for Agency use only. Your candid and open responses are helpful in enabling us to assess the applicant’s ability to serve as a CASA volunteer.

Person Completing the Form

First Name *

Last Name *

Applicant's Name

First Name *

Last Name *

All Information received will be held confidential in every respect

1. How long have you know the applicant? (Required)

In what capacity? (Required)

Please rank the applicant on the following by circling the ranking numbers, 1 being the highest and 5 being the lowest in the applicant’s abilities. If you have had no opportunity to observe the applicant in a particular capacity, please note that by circling “U” for Unknown.

A. Applicant’s ability to relate to own children and/or children of others?

1. Able
2
3
4
5. Not Able
U

B. Ability to use and maintain confidential information:

1. Able
2
3
4
5. Not Able
U

C. Ability to remain objective in difficult situations and maintain respect for differing values or views:

1. Able
2
3
4
5. Not Able
U

D. Ability to problem solve or reach decisions, and work independently:

1. Able
2
3
4
5. Not Able
U

E. Ability to carry out assignments in a timely manner:

1. Able
2
3
4
5. Not Able
U

F. Verbal communication skills:

1. Able
2
3
4
5. Not Able
U

G. Written communication skills:

1. Able
2
3
4
5. Not Able
U

H. People-skills and listening ability:

1. Able
2
3
4
5. Not Able
U

I. Maturity, stability, sound judgment and sound character:

1. Able
2
3
4
5. Not Able
U

J. Openness to learning, ability to accept supervision and direction:

1. Able
2
3
4
5. Not Able
U

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K. Concern for children, and an understanding of family relationships:

1. Able
2
3
4
5. Not Able
U

L. Ability to respect and relate to people from various backgrounds and lifestyles (economic, cultural, educational, etc.) in a variety of settings:

1. Able
2
3
4
5. Not Able
U

2. Do you have any concerns about the applicant’s ability to work with children or suitability for a CASA type program? (Required)

3. To your knowledge, has the applicant ever:

Been convicted of a crime other than a minor traffic offense?

If yes, please explain

Been arrested or undergone residential treatment for drug-related or alcohol-related reasons? (Including, but not limited to, driving under the influence)

If yes, please explain:

Been reported to or investigated by a law enforcement agency or a child protective agency for abuse, neglect, molestation, abandonment or failure to protect a minor?

If yes, please explain:

Had a minor removed from their custody, guardianship, or placement by a court order?

If yes, please explain:

Committed a violent crime and/or a crime against a child?

If yes, please explain:

4. Comments: Please candidly express any support for or concerns about the applicant. Feel free to suggest other referral sources (name and phone number) that you believe will assist in our decision. This is for the safety and protection of our children as well as the potential volunteer. (Required)

By typing in my name and checking the box below, I agree that I have answered the above questions to the best of my ability.

Name

First Name *

Last Name *

Date (Required)

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Cell Phone Number (Required)