Reference Request

Candidate
NI Number
Capacity in which you know the candidate*
Length of time you have known the candidate*
Dates in your employment
From:
Date Format: DD slash MM slash YYYY
To:
Date Format: DD slash MM slash YYYY
How was the employment terminated
- Resignation
- Redundancy
- Dismissal
- Retirement
Please provide reason for dismissal
Would you re-employ this candidate?
- Yes
- No
If no, please give details:
Is there a current disciplinary record for this candidate
- Yes
- No
If yes, please give details:
To your knowledge has the candidate had any vehicle accidents which led to any insurance claims as a result of their driving whilst on duty?
- Yes
- No
If yes, please give details:
Please indicate the sick record for the past 12 months*
Number of Days & Number of Episodes
Is there a current live period of sickness review for this individual?
E.g. 6 month informal review.
- Yes
- No
Total length of review
Expiry date of review
Date Format: DD slash MM slash YYYY

Assessment
Please assess the candidate in relation to the following:
Honesty & Trustworthiness*
Comments:
Time Keeping*
Comments:
Conduct*
Comments:
Performance in post*
Comments:
Ability to work with others*
Comments:
Ability to work unsupervised*
Comments:
Management of staff (if applicable)*
Comments:
Professional IT ability (if applicable)*
Comments:
Acceptance of responsibility*
Comments:
Reliability under pressure*
Comments:
Ability to carry out instructions*
Comments:
Written communication skills*
Comments:
Verbal communication skills*
Comments:
Do you know of any reason why this person should not work with vulnerable adults and/or children?*

Declaration
I confirm that I am authorised to give reference details on behalf of:
Company/Organisation
Name
Position
Date
Date Format: DD slash MM slash YYYY
Telephone Number

Assessment