Reference Request

You have been listed as a referee for the individual we have emailed you about. We would be very grateful if you would be able to take a few minutes to complete this reference form. Any information provided will be kept confidential.

Position candidate has applied for will be in a care home for the elderly where most residents are confused and dependant.

I have known the candidate since

Attributes/Skills - Please rate in terms of each the following

Quality of work performed



Ability to work within a team

Ability to work unsupervised

Ability to communicate with colleagues at all levels

Ability to communicate with residents/relatives

Attention to detail

Clinical ability and professionalism

Management skills


Willingness to learn

Please give your opinion as to his/her abilities in relation to position applied for:

Health: does this person have any disability or have they had any periods of sickness? Please give details

The following questions are to be completed by former employers only:
Please state the company/organisation in which you worked with the candidate?
During the past year have there been any occasions where it has been necessary to counsel the candidate under you disciplinary/performance procedures?
If yes please give details
Are you aware of any criminal convictions?
If yes please give details
Did the applicant take parental leave?
a) If so for how long?
b) and what was the name of the child?
How much time off work has the candidate taken, in the previous 12 month period?
a) Total number of days:
b) Longest period of absence:
If the candidate no longer works for you what was the reason for leaving your employment?

If other please specify
Would you re-employ this person?
If not, why not?
Any other comments you feel are relevant to the position applied for?

All references will be treated with the strictest confidence. However, in accordance with the Data Protection Act 1998 successful applicants have the right to see any references provided for them unless the referee has specifically asked to not allow access to the reference. There must be a compelling reason for them not to have access. I should therefore be grateful if you would indicate whether this applicant could have access to the reference you provide.

Please select as appropriate:
objections to allowing them access to this reference

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