Employee Reference Request

REFERENCE REQUEST FOR*

Your Name & Position*

Company Name & Address where worked with candidate*

Relationship with candidate*

Date Employed From*

Date

Date Employed To*

Date

Candidates Job Title*

Reason For Leaving*

Re-employ?*

YesNo

Comments/further information

General Conduct*

ExcellentGoodSatisfactoryPoor

Timekeeping*

ExcellentGoodSatisfactoryPoor

Communication Skills*

ExcellentGoodSatisfactoryPoor

Relationship with colleagues/nursing staff*

ExcellentGoodSatisfactoryPoor

Relationship with patients/service users*

ExcellentGoodSatisfactoryPoor

Has the candidates honesty and integrity ever been brought into question that you are aware of? (Please comment)*

Level of performance*

ExcellentGoodSatisfactoryPoor

Do you consider the candidate to need Clinical or Behavioural Development?*

Are you aware of any suspicious proceedings, Policy investigations or disciplinary action?*

Additional comments. If you have ticked satisfactory or poor for any of the above please provide us with further explanatory information

I declare that to the best of my knowledge the information I have given in this reference is correct and complete*

I Agree

E-mail

example@example.com

Phone Number

Area CodePhone Number

Signature: Signature
Date: Date

1. Employment Details