Reference Form

Name

First Name Last Name

Email

example@example.com

Phone Number

Job Title

Company

In what capacity do you know the applicant

Applicant Details.

Name

First Name Last Name

Job Title

Company

Date Employed From

Date

Date Employed To

Date

Would You Re-employ this person

Yes No

SECTION 1 - HOW WOULD YOU ASSESS THE FOLLOWING?

Please tick the relevant boxes, Execellent, Good, Average, Fair.

Ability to follow care plan

Excellent Good Fair Poor

Excellent Good Average Poor Reliability, timekeeping,attendance

Excellent Good Fair Poor

Attitude

Excellent Good Fair Poor

Character

Excellent Good Fair Poor

Ability to Unsure Dignity is Upheld

Excellent Good Fair Poor

Ability to follow care plan

Excellent Good Fair Poor

Communication

Excellent Good Fair Poor

Relationship With Colleagues

Excellent Good Fair Poor

Ability to Work Under Own Initiative

Excellent Good Fair Poor

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?

Yes No

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

Yes No

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

Yes No

Has the applicant been subject to any disciplinary action?

Yes No

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

Yes No

Additional Comment

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

Confirmation

Yes No

Reference Form

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