Reference Request Form

    Position Applied for

    Name of Applicant

    Job Applied for
    (please refer attached job description)

    Please Outline

    Capacity in which you know the Applicant

    How long have you known the Applicant?

    Job held by Applicant

    Dates of Employment

    Reason for leaving

    Any formal disciplinary warnings issued during the applicants employment with you for performance, attendance or conduct?
    If Yes, please provide details to include of level of warning; date issued and duration

    Have you referred the Applicant to DBS (England & Wales), SSSC or PVG (Scotland), NMC or any other regulatory or professional body?
    If Yes, please provide details

    Would you re-employ the candidate? If no, why not?

    Record of Parental Leave

    Number of days applicant has taken parental leave

    Please provide an overview of the applicant’s key duties & responsibilities whilst in your employment.

    Please assess against these performance criteria (please tick(√) as appropriate)







    Honesty & Integrity

    Standard & Quality of Work

    Attitude & Behaviour

    Approach to Teamwork

    Attitude to Workload

    Attitude to working within Guidelines

    Please comment on the candidate’s suitability for the post (refer attached job description) taking into
    account ability, professional and personal characteristics as well as managerial ability, if appropriate,
    and any other factors which you consider relevant.

    Please use the space below, to provide any additional information you think may be relevant.

    In signing this document you agree that the information provided is a) accurate and b) unless you
    indicate to the contrary, you consent under the General Data Protection Regulation to this information
    being disclosed to a third party such as the employee to whom this reference applies.

    Please tick (√) as appropriate. .



    Position / Job Title