Reference

Applicant Name *

First

Last

The full name of the person being referred.

Please confirm employment dates: From

How do you know the applicant?

seeking? following: Organisation

Reasons for leaving your employment

NB. Where the applicant has previously worked in a position which involved contact with children or vulnerable adults, written verification giving reasons why they ceased to work in that position is required. Please use a separate sheet if necessary.

Would you re-employ them? (If not, please give reasons for not doing so)

Please comment on the following:

Honesty *

Reliability *

Are they trustworthy? *

Their ability to work with others and on own initiative *

Their suitability as an employee who will have responsibility for people with disabilities and whom share the Trust’s values of: Kindness, Respect, Individuality and Working Together? *

Timekeeping *

Good
Bad
Average

Which of the words listed below best describes the applicant’s timekeeping and attendance?

Do you consider the applicant to be a responsible individual able to adopt a flexible attitude to changing situations? *

Health: How many sick days has the applicant had in the last two years and on how many occasions?

Please give any additional information you feel is relevant regarding the applicant’s experience to date, their strengths and weaknesses and general aptitude for the post they are seeking? *

Were there any safeguarding issues during their employment with you?

Were there any incidents of concern during their work with you?

Has disciplinary action ever been taken?

Do you know of any reason why we should not ask them to work with us?

Reference Name *

First

Last

The full name of the person providing the reference.

Phone *

Organisation *

Position / Title *

Date *

Reference

Please comment on the following:

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