Dd-403-Pf - Reference Request - Arizona Department Of Economic Security
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DD-403-PF (12-05)
(Refer to A.A.C. R6-6-1504
Division of Developmental Disabilities
(Replaces DD-403-A,B,C,D)
Home and Community Based Services (HCBS)
REFERENCE REQUEST
APPLICANT
This reference request should be provided to a person who has personal knowledge about your employment history, education or
character and can attest to your ability to provide services. Two references should be from former/current employers. References
CANNOT be from family members. Please fill in your name below and give to the person you are requesting a reference from.
Instruct the person to mail this Reference Request back to the Division of Developmental Disabilities (DDD).
APPLICANT’S NAME (Last, First, M.I.)
APPLICANT’S ADDRESS (No., Street, City, State, ZIP)
APPLICANT’S PHONE NO.
(
)
PERSON PROVIDING REFERENCE
Please complete the questions listed below keeping in mind that Home and Community Based Services (HCBS) may be performed
unsupervised in the home of the person with developmental disabilities or in the residence/facility of the applicant. Your time and
effort in completing this form is appreciated and strict confidentiality in regard to your responses will be observed within the
provisions of the law.
This reference request MUST be returned to the HCBS local office listed on the reverse. If mailing, fold this form in half with the
DES/DDD address on the outside, seal lower edge (NO STAPLES), attach stamp and mail.
PRINT PERSON’S NAME PROVIDING REFERENCE (Last, First, M.I.)
ADDRESS (No., Street, City, State, ZIP)
DAYTIME PHONE NO.
EVENING PHONE NO.
(
)
(
)
STATE THE LENGTH OF TIME YOU HAVE KNOWN THE APPLICANT
Years:
Months:
TYPE OF ACQUAINTANCE (Check all that apply)
Supervised applicant
Worked with applicant
Friend
Neighbor
Other:
INDICATE YOUR FEELINGS ON HOW YOU BELIEVE THE APPLICANT WILL RELATE TO INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES. DESCRIBE YOUR
KNOWLEDGE OF ANY CHARACTERISTICS AND/OR SPECIAL TRAINING/EDUCATION THAT THE APPLICANT MAY HAVE FOR WORKING WITH THESE
INDIVIDUALS.
INDICATE IF YOU HAVE ANY REASON TO BELIEVE THAT THE APPLICANT WOULD NOT BE SUITED TO PROVIDE SERVICES TO INDIVIDUALS WITH
DEVELOPMENTAL DISABILITIES.
IF THE APPLICANT WAS A FORMER EMPLOYEE, WOULD YOU REHIRE THIS PERSON?
No
Yes
N/A
If no, why not?
ADDITIONAL COMMENTS WHICH WILL HELP IN EVALUATING THIS APPLICANT
PERSON’S SIGNATURE PROVIDING REFERENCE
DATE
FOR OFFICE USE ONLY
INTERVIEWED BY PHONE
DATE
No
Yes
PRINT INTERVIEWER’S NAME (Last, First, M.I.)
INTERVIEWER’S SIGNATURE
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