Reference Request 1Details2Assessment3Declaration Candidate NI Number Capacity in which you know the candidate* Length of time you have known the candidate* Dates in your employmentFrom: DD slash MM slash YYYY To:To: DD slash MM slash YYYY How was the employment terminated Resignation Redundancy Dismissal Retirement Please provide reason for dismissalPlease provide reason for dismissal Would you re-employ this candidate? Yes No If no, please give details:If no, please give details: Is there a current disciplinary record for this candidate Yes No If yes, please give details: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: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 reviewTotal length of review Expiry date of reviewExpiry date of review DD slash MM slash YYYY AssessmentPlease assess the candidate in relation to the following:Honesty & Trustworthiness*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Time Keeping*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Conduct*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Performance in post*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Ability to work with others*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Ability to work unsupervised*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Management of staff (if applicable)*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Professional IT ability (if applicable)*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Acceptance of responsibility*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Reliability under pressure*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Ability to carry out instructions*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Written communication skills*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Verbal communication skills*ChooseGoodSatisfactoryUnsatisfactoryNot ApplicableComments:Comments: Do you know of any reason why this person should not work with vulnerable adults and/or children?* DeclarationI confirm that I am authorised to give reference details on behalf of:Company/Organisation Name Position Date DD slash MM slash YYYY Telephone Number
