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Reference Form
Complete the reference form and submit
Referee Details
Name
*
First
Last
Phone
*
Email
*
Job Title
Company
*
In what capacity did you know the applicant?:
*
Applicant Details
Name
*
First
Last
Job Title
Company
Date Employed from:
*
MM slash DD slash YYYY
Date Employed to:
*
MM slash DD slash YYYY
Would you re-employ this person?
*
Yes
No
Please explain why you would not re-employ them.
*
SECTION 1 - HOW WOULD YOU ASSESS THE FOLLOWING?
Please tick the relevant boxes Excellent, Good, Average, Poor
Ability to follow care plans
*
Excellent
Good
Average
Poor
Reliability, timekeeping,attendance
*
Excellent
Good
Average
Poor
Character
*
Excellent
Good
Average
Poor
Attitude
*
Excellent
Good
Average
Poor
Ability to ensure dignity is upheld
*
Excellent
Good
Average
Poor
Communication
*
Excellent
Good
Average
Poor
Relationships with colleagues
*
Excellent
Good
Average
Poor
Ability to work under own initiative
*
Excellent
Good
Average
Poor
SECTION - 2 Please answer the following questions
Please tick the relevant boxes Excellent, Good, Average, Poor
Has the applicant been subject to any disciplinary action?
*
Yes
No
Please provide details:
*
Are you aware of the applicants involvement in any safeguarding investigations previous or current .
*
Yes
No
Please provide details:
*
Are you aware of any reasons why the applicant should not be employed to work with children or vulnerable people?
*
Yes
No
Please provide details:
*
To the best of your knowledge, has the applicant been convicted or cautioned of a criminal offence?
*
Yes
No
Please provide details:
*
Additional Comments
PLEASE CONFIRM:
I can confirm that all the details provided are accurate at the time that this reference was completed. I can confirm that I am authorised to provide a reference on behalf of my organisation. I understand this reference may be shown to a third party for auditing purposes and I can confirm that Local Care Force has this organisation s consent and authorisation to disclose the contents of this reference to its end user, hirer clients. I understand that the applicant has the legal right to request a copy of their reference.
*
Check to confirm
Official company stamp.
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