Professional Reference Form

Declaration : *

Yes, I agree with the privacy policy and terms and conditions.

It is Chelmscare’s policy to obtain a written reference for prospective applicants prior to confirming their employment.

We would be most grateful if you comment on the applicant’s appropriateness for the role, they have applied for by completing the “reference” form below. This will assist us in assessing the applicant’s suitability and progress their job application further. Please be assured that all information is kept in the strictest confidence.

Please note that as to protect the public the post for which the application has been made is exempt from Section 4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the exemption order, 1975. It is not therefore in any way contrary to the act to reveal any information you have concerning conviction, including those which would otherwise be considered spent. Any information will of course be kept in strict confidence and used only in consideration of the suitability of this applicant for the position stated.

SECTION 1 :

CONFIRMATION OF EMPLOYEMENT :

Date of Issue : *

Full Name: *

Position Applied :

Employment commence date : *

Employment end date : *

Position while employed : *

Reason for leaving ( if known )

SECTION 2 :

General Information

Would you re-employee the above named individual ? *YesNo

In your opinion is the applicant suitable for the position applied for ? *YesNo

Is the applicant an honest and trustworthy individual ? *YesNoThis field is required.

Was any disciplinary action taken or pending against the applicant ? *YesNo

Are you aware of any back or neck injuries ? *YesNo

If you have ticked "YES" to any the above questions, please provide additional information :0 / 500

How many sick days has the applicant had off in the past 12 months of employment ? *

SECTION 3 :

General Performance

Attitude to work : *AcceptableNeeds DevelopementStrongOutstanding

Attendance : *AcceptableNeeds DevelopementStrongOutstanding

Reliability : *AcceptableNeeds DevelopementStrongOutstanding

Working relationship with other staff members : *AcceptableNeeds DevelopementStrongOutstanding

Skills : *AcceptableNeeds DevelopementStrongOutstanding

Experience : *AcceptableNeeds DevelopementStrongOutstanding

Quality of work : *AcceptableNeeds DevelopementStrongOutstanding

Time Keeping : *AcceptableNeeds DevelopementStrongOutstanding

Please add any remark that you think may be relevent to our decison as whether we should employ the applicant.0 / 500

SECTION 4 :

E-Signature *

Full name : *

Position : *

Date : *