Reference Form

Reference Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Job Title
Company
In what capacity do you know the applicant
Applicant Details.
Name

First NameLast Name
Job Title
Company
Date Employed From

DayMonthYear
Date
Date Employed To

DayMonthYear
Date
Would You Re-employ this person

YesNo
SECTION 1 - HOW WOULD YOU ASSESS THE FOLLOWING?

Please tick the relevant boxes, Execellent, Good, Average, Fair.
Ability to follow care plan

ExcellentGoodFairPoor
Excellent Good Average Poor Reliability, timekeeping,attendance

ExcellentGoodFairPoor
Attitude

ExcellentGoodFairPoor
Character

ExcellentGoodFairPoor
Ability to Unsure Dignity is Upheld

ExcellentGoodFairPoor
Ability to follow care plan

ExcellentGoodFairPoor
Communication

ExcellentGoodFairPoor
Relationship With Colleagues

ExcellentGoodFairPoor
Ability to Work Under Own Initiative

ExcellentGoodFairPoor
SECTION - 2 Please answer the following questions

Please tick the relevant boxes. Excellent , Good,Average, Fair, Poor
Has the applicant been subject to any disciplinary action?

YesNo
Are you aware of the applicants involvement in any safeguarding investigations previous or current

YesNo
Are you aware of any reasons why the applicant should not be employed to work with children or vulnerable people?

YesNo
Has the applicant been subject to any disciplinary action?

YesNo
To the best of your knowledge, has the applicant been convicted or cautioned of a criminal offence?

YesNo
Additional Comment
I can confirm that all the details provided are accurate at the time this reference was completed.
Confirmation

YesNo
Should be Empty: