Clone of Employee Reference Request (Schools)

Healthcare Employee Reference Request
Reference Request For:*

First NameLast Name
Date employed from

DayMonthYear
Date
Date employed to

DayMonthYear
Date
Was the position:*

PermanentContractSupply
Was the employment:*

Full TimePart Time
If the employment was part time, please confirm the hours worked per week
Name of establishment employed at*
Establishment type:*

HospitalGP SurgeryClinicNursing/Residential HomeSchoolOther
Position held by applicant*
Please confirm professional relationship with applicant:
(for example: Manager, Clinical Supervisor, Employer etc.)
What were the applicants professional responsibilities:
Would you re-employ the applicant?*

YesNo
If you selected No, please elaborate below
Reason/s for leaving your employment/workplace?*
Was the applicant undergoing any stage of disciplinary proceedings or subject to any investigation when they left your employment?*

YesNo
If you selected 'Yes', please provide details below

Please grade the applicant on the following by selecting the boxes that most closely correspond to their competence level:

Pupil/class control & discipline*

ExcellentGoodAveragePoorNot Applicable
Professionalism & conduct*

ExcellentGoodAveragePoorNot Applicable
Teaching ability*

ExcellentGoodAveragePoorNot Applicable
Preparation & planning*

ExcellentGoodAveragePoorNot Applicable
Relationship with students*

ExcellentGoodAveragePoorNot Applicable
Suitability for a supply position*

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

I Agree
Your Name *

First NameLast Name
Your Position*
Employer Name
E-mail*
example@example.com
Phone Number
Signature*

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Healthcare Employee Reference Request