Employment Reference Request Form
Please answer all questions honestly and accurately as possible. If you are unable to answer some sections, please write ‘N/A’.
Applicants Name
Employment Details
Employment From
/
Day
/
Month
Year
Date
Employment To
/
Day
/
Month
Year
Date
Job Title
Nature of work
Reason for leaving employment?
End of Contract
Illness
Underperformance
Personal Reasons
Other
During employment, was the applicant subject of a disciplinary procedure?
Yes (if yes, please give details below)
No
Details of disciplinary
How many periods of sickness absence did they have?
Would you re-employ applicant?
Yes
No (if no, please give details below)
Details on Re-employment
Would you recommend the applicant for the role of carer
Yes
No (if no, please give details below)
Please give details below
Back
Next
Please rate the applicant on the following competencies and add any comments in the box at the end of the section
Ability to plan, structure and prioritise own work
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Ability to learn from situations and past experience
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Ability to be flexible and adapt to new ways of working
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Ability to work hard to achieve objectives and goals
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Capacity to remain calm under pressure
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Willingness to work together as a team
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Ability to use own initiative
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Ability to communicate potential issues before they arise
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Time-keeping
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Do you have any additional comments
Your Name
Position
Date
/
Day
/
Month
Year
Date
Submit
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