Four Plus Solutions - Reference Request Form

Assess the candidate on the following criteria*

	Excellent	Good	Average	Poor	Not Applicable
Attendance
Clinical Skills
Communication Skills
Organisational Ability
Patient Records / Record Management
Professional Integrity
Punctuality
Relationship with Patients and Colleagues
Reliability
Supervisory Skills

Do you consider the reviewed suitable for their respective role or position identified*

YesNo
If no, please provide details
Would you re-employ the candidate?*

YesNo
Any additional details or comments
Please confirm whether you have witnessed the candidate provide safe drug administration within the last 12 months. (Applicable if the reviewed is a nurse)*

YesNoNot Applicable

3. Referee Details
Your Name*

First NameLast Name
Organisation / Company*
Please enter the name of the Organisation / Company you represent
Your Designation (Band / Grade)*
Please note, you must be a higher designation than the candidate
Your Email - this must be a work / professional email, not personal*

Confirmation Emailexample@example.com
Date of Completion*

DayMonthYear
Date
Referee Signature*

Clear
Thank you for taking the time to complete this reference request.
Recipient Email (HR)*
example@example.com
Should be Empty: