Nurses Reference form - Alas HealthCare

Reference form (Nurse)

REFERENCE REQUEST FORM

Note: In order to protect the public you are free to divulge any information you have regarding criminal convictions that are relevant to this applicant's request for employment. This is provided for by virtue of the 1975 Exceptions Order to Section 4 (II) of the Rehabilitation of Offenders Act (1974).

Applicant Fullname

Position applied for:

In what capacity do you know the Individual mentioned?

Current Employee

Former Employee

Other

If other Specify

How long have you known/did you know the applicant?

If employed, from when?

Position(s) held

Enter the position

Their reason(s) for leaving

Enter the reasons

Would you re-employ this person?

Yes

Disciplinary Action: Is there a current warning on file or are they the subject of any current disciplinary action or enquiry? Yes/No If yes to either question, please supply details. How much absence did they have in their last 12 months of employment, excluding holidays? Number of days Number of occasions

Yes

If Yes Specify

Do you know of any criminal convictions or police/court cautions or warnings in respect of the applicant? Yes/No If yes, please supply details, on a separate page if necessary.

Yes

If Yes Specify

Please give your opinion of the applicant in regard of the following (tick as appropriate)

	Excellent Good	Acceptable Poor
Punctuality/Reliability
Professional Conduct/Dedication
Standard of Work/Performance
Self-Motivation/Initiative
Verbal Communication Skills
Written Communication/Paperwork Skills
Leadership Skills/Potential
Coping under Pressure
Co-operation/Teamwork
Confidence/Ability to Work
Unsupervised
Attitude to Training/Improvement
Caring Nature
Positive Role Model

What other information do you have regarding their suitability for the position and the various tasks, responsibilities and personal attributes required for it?

Signature

Move your cursor or hand over to sign

Full Name

Position

Company

Date

Agency Overview

Alas Healthcare covers Southampton and surrounding areas and offers a comprehensive range of personal and practical agency to provide carers and nursing staff for organisations providing service to people who need assistance due to illness to enable them to continue living in their own home, in accordance with their own lifestyle, and with independence, safety, and respect.

REFERENCE REQUEST FORM

Agency Overview

Our Services

Contact Details