Healthcare Employee Reference Request
Reference Request For:
*
First Name
Last Name
Date employed from
-
Day
-
Month
Year
Date
Date employed to
-
Day
-
Month
Year
Date
Was the position:
*
Permanent
Contract
Supply
Was the employment:
*
Full Time
Part Time
If the employment was part time, please confirm the hours worked per week
Name of establishment employed at
*
Establishment type:
*
Hospital
GP Surgery
Clinic
Nursing/Residential Home
School
Other
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?
*
Yes
No
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?
*
Yes
No
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:
Rows
Excellent
Good
Average
Poor
Not Applicable
Expertise
Professionalism & conduct
Patient-centred care
Preparation & planning
Teamwork & collaboration
Pupil/class control & discipline
*
Excellent
Good
Average
Poor
Not Applicable
Professionalism & conduct
*
Excellent
Good
Average
Poor
Not Applicable
Teaching ability
*
Excellent
Good
Average
Poor
Not Applicable
Preparation & planning
*
Excellent
Good
Average
Poor
Not Applicable
Relationship with students
*
Excellent
Good
Average
Poor
Not Applicable
Suitability for a supply position
*
Excellent
Good
Average
Poor
Not 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 Name
Last Name
Your Position
*
Employer Name
E-mail
*
example@example.com
Phone Number
Format: (000) 000-0000.
Signature
*
Submit
Submit
Should be Empty: