Health care assistant Reference form REFERENCE REQUEST FORMNote: 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).Position applied for: Health Care AssistantIn what capacity do you know the Individual mentioned? Current Employee Former Employee OtherIf 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 NoDisciplinary 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 NoIf 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 NoIf Yes Specify Please give your opinion of the applicant in regard of the following (tick as appropriate)Excellent GoodAcceptable PoorPunctuality/ReliabilityProfessional Conduct/DedicationStandard of Work/PerformanceSelf-Motivation/Initiative Verbal Communication SkillsWritten Communication/Paperwork SkillsLeadership Skills/PotentialCoping under PressureCo-operation/TeamworkConfidence/Ability to WorkUnsupervisedAttitude to Training/ImprovementCaring NaturePositive Role ModelWhat 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 Submit Recommendation
