Reference Request YOUR DETAILS Your Name Your Email Your Phone Number APPLICANTS PERSONAL DETAILS Name of applicant How long have you known the applicant? In what capacity do you know this person? In what capacity do you know this person? Friend Family Colleague Line Manager Other Position Applied For? Position Applied For? Registered Manager Senior Care Coordinator Care Coordinator Field Supervisor Domiciliary Care Worker Night Care Worker Live-in Care Worker THEIR CURRENT JOB Job Held by applicant Start Date Of Employment? End Date Of Employment? SKILLS & PERFORMANCE Punctuality: Punctuality: Excellent Good Satisfactory Poor Attitude: Attitude: Excellent Good Satisfactory Poor Communication: Communication: Excellent Good Satisfactory Poor Ability to work unsupervised: Ability to work unsupervised: Excellent Good Satisfactory Poor Reliability: Reliability: Excellent Good Satisfactory Poor Honesty: Honesty: Excellent Good Satisfactory Poor Job Competence: Job Competence: Excellent Good Satisfactory Poor Appearance: Appearance: Excellent Good Satisfactory Poor ADDITIONAL INFORMATION Please tell us about their teamwork? As far as you know, has this person ever been convicted of a criminal offence? As far as you know, has this person ever been convicted of a criminal offence? Yes No I am not sure Are you aware if the applicant has had any cautions or warnings of a criminal offence? Are you aware if the applicant has had any cautions or warnings of a criminal offence? Yes No I am not sure Would you re-employ this person? Would you re-employ this person? Yes No I don't know DECLARATION In signing this document, you agree that the information is accurate and unless stated otherwise, you consent under the Date Protection Legislation to this information being disclosed to a third-party such as the applicant to whom this reference applies. In signing this document, you agree that the information is accurate and unless stated otherwise, you consent under the Date Protection Legislation to this information being disclosed to a third-party such as the applicant to whom this reference applies. I agree I disagree END OF REFERENCE 6 + 5 = Complete
