Reference Request Form

Fields marked • are required.

• Applicant's Surname • Applicant's Forename • Date of Birth Applicant Worked At Organisation Address Position Professional Relationship with Individual Please state the reason why this person is leaving/has left your employment Would you re-employ this applicant? If no, please state reason why Please assess these performance criteria: Reliability Punctuality and Attendance Efficiency Professionalism Judgement Under Pressure Ability to Prioritise Tasks Oral Communication Written Communication Working as Part of a Team Relationship With Managers Relationship with Service Users Please Complete the Following Information: 1. Please can you provide a brief overview on the position the applicant held: 2. Please can you provide details of any training/induction the applicant completed when they were in your employment: 3. Please can you provide details of any qualifications the applicant completed when they were in your employment: Other (Please Specify): 4. Please comment on the attendance record of the applicant: 5. Do you have any concerns regarding the applicant's honesty or integrity? 6. Has this person ever been part of any disciplinary action whilst in your employment? If Yes, Please Provide Details 7. Does your organisation have a policy on expunging disciplinary records from personal files? If Yes, After What Period of Time? 8. Since this post is considered exempt from the provision of the Rehabilitation of Offenders Act 1974 (Exemptions Order 1986), it would be in order for you to reveal any information you have about any convictions received by this person. Therefore, please can you provide any information that you have: 9. Do you have a current disclosure check on this applicant? 9a. Was the Disclosure clear of any information relating to this applicant? Did the job role involve working with children or young people? (If yes, go to Q.10. If no, go to Q.13.) 10. In your professional capacity please state the applicant's overall suitability to work with children: 11. Please can you comment on the applicant's ability to work with parents and carers: 12. Please can you comment on the applicant's behaviour management ability: 13. To the best of your knowledge, has this person ever been part of any safeguarding investigation? 14. Please add any comments you may wish to add about this applicant's overall ability and skills to worth with children: Unless otherwise stated we will assume that you do not have any objection to the contents of this reference being disclosed to prospective employers. Please place a tick in the box provided if this is not acceptable to you • Name: • Position: Thank you for taking the time and trouble to assist us.

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