CHCM - Certified Hazard Control Manager / CHSP - Certified Healthcare Safety Professional / CPSO - Certified Patient Safety Officer 

CHEP - Certified Healthcare Emergency Professional / CPSM - Certified Product Safety Manager

CHCM

CHSP

CPSO

CHEP

CPSM

 

INTERNATIONAL BOARD FOR CERTIFICATION OF SAFETY MANAGERS

173 Tucker Road, Suite 202

Helena, Alabama 35080

 

(Remit To Address: (BCHCM) P.O. Box 515   Helena, AL 35080)

 

Executive Director: Jim Tweedy

Phone: 205-664-8412 Fax: 205-663-9541

Email: Information@chcm-chsp.org

ON-LINE REFERENCE EVALUATION FORM

 

Please Fill Out Reference Evaluation From Below As Thoroughly As Possible and Hit The Submit Reference Form Button When Finished.

 

Check Relevant Certifications

 

 

CHCM    CHSP   CPSO    CHEP    CPSM  

 

 

Name Of Applicant :  Has submitted an application for certification and has selected you as an individual who can provide an assessment of professional attainment that he or she has achieved. Please answer all questions as completely and promptly as possible to expedite the processing of the application. All information furnished will be confidential. Thank you for your cooperation.

 

 

1. I have known the applicant since (month, year): 

 

2. Under what circumstances have you been able to form a judgment of the applicant’s capabilities?

 

3. If your association with the applicant has a bearing on his or her hazard control, safety management, or other responsibilities, briefly describe how the applicant performed.

 

4. List applicant’s achievement or accomplishments in the field of hazard control management, safety, or other related field.

 

5. Appraisal Of Management/Technical Skills and Knowledge

 

INSTRUCTIONS: From your personal knowledge give your evaluation by marking the column which best expresses your appraisal of the candidate. 

The rating for each column is:

1 = Excellent                                2 = Good                                 3 = Satisfactory                           4 = Poor

 

PART I – MANAGEMENT CAPABILITIES

1 – E

2 – G

3 – S

4 - P

1. Analytical skills

 

 

 

 

2. Oral expression

 

 

 

 

3. Writing Ability

 

 

 

 

4. Ability to supervise

 

 

 

 

5. Creativity in devising solutions to management problems

 

 

 

 

6. Initiative in setting program objectives

 

 

 

 

7. Follow through in completing tasks and assignments

 

 

 

 

8. Personal working relationships

 

 

 

 

9. Ability to motivate and involve middle and top level managers

 

 

 

 

 

PART II – KNOWLEDGE AND APPLICATION OF HAZARD CONTROL OR SAFETY PRINCIPLES

1 – E

2 – G

3 – S

4 - P

10. Program planning and development

 

 

 

 

11. Program evaluation

 

 

 

 

12. Technique of data collection and statistical methods

 

 

 

 

13. Knowledge of codes, standards and regulations

 

 

 

 

14. Identification and analysis techniques

 

 

 

 

15. Techniques of accident prevention and safety control

 

 

 

 

 

 

6. Are there any reasons why you would not recommend that the applicant be certified?  

YES     NO

(If YES explain below)

 

 

7. Reference Information:

Your Name and Title:

   

 

Organization and Division:

   

 

Work Address:

 

 City, State, Zip Code:

 

Telephone Number / Extension:

 

E-mail Address:

 

 

My digital signature below attests to the veracity of the information submitted above.

 

8. Signature and Date: