REFERENCE REQUEST FOR
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Click to enter the full name of the candidate
Your Name & Position
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Company Name & Address where worked with candidate
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Relationship with candidate
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1. Employment Details
Date Employed From
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Day
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Month
Year
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Date Employed To
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Day
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Month
Year
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Candidates Job Title
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2. Please Comment On The Following
Do you believe the named applicant to be honest, conscientious and discreet?
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Yes
No
Clinical skills demonstrated in line with the requirements of the position
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Excellent
Good
Satisfactory
Poor
Relationship with patients, other healthcare workers and the public
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Excellent
Good
Satisfactory
Poor
Communication Skills
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Excellent
Good
Satisfactory
Poor
Timekeeping
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Excellent
Good
Satisfactory
Poor
Level of performance
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Excellent
Good
Satisfactory
Poor
Patient records and other records management
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Excellent
Good
Satisfactory
Poor
Reliability
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Excellent
Good
Satisfactory
Poor
Communication Skills
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Excellent
Good
Satisfactory
Poor
Supervisory skills
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Excellent
Good
Satisfactory
Poor
Organisational ability and workload management
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Excellent
Good
Satisfactory
Poor
Sickness / absence record
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Excellent
Good
Satisfactory
Poor
Additional comments in support of statements
Do you know of any factors surrounding the named applicant that may affect his/her fitness for employment or any reasons why the named applicant should not work in a clinical environment?
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Yes
No
If yes, please provide further information;
Are you aware of any suspicious proceedings, Policy investigations or disciplinary action?
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Are you aware of any criminal convictions(s) relating to the applicant
Yes
No
If yes, please provide further information;
Have you had any reason to instigate disciplinary action against the named applicant?
Yes
No
If yes, please provide further information;
Has the named applicant been, or is he/she currently the subject of any fitness to practice proceedings by an appropriate licensing or regulatory body?
Yes
No
If yes, please provide further information;
Do you consider the named applicant suitable for the position identified for?
Yes
No
If no, please provide further information;
I declare that to the best of my knowledge the information I have given in this reference is correct and complete
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I Agree
E-mail
Phone Number
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Area Code
Phone Number
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