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Reference Form




  






How long did the applicant work for you/with you or under your supervision and in what capacity / specialist area?






Please state the nature and depth of your acquaintance to the named applicant?

Do you consider the applicant to be honest, conscientious and discreet? If not, please provide further details below.

Do you know of any factors surrounding the named applicant that may affect his/her fitness for employment, or any reason why the named applicant should not work in a clinical environment? If yes please provide further details below.

 

Please select from the choices and provide additional comments in support of the statements made. We have pre-selected for your convenience but please change as appropriate.

 











 
Additional comments in support of the statements made above:

Nurses only: Is the applicant competent at performing IV Cannulation?
Nurses only: Is the applicant competent at performing IV Drug Administration & Therapy?
Nurses only: Is the candidate fully trained in IV Cannulation and/or IV Drug Administration & Therapy?
Has the named applicant been, or is he/she currently the subject of any fitness to practice proceedings by an appropriate licensing or regulatory body in the UK or any other country? If yes please give detail.
Have you had any reason to instigate disciplinary action against the named applicant? If yes please give details below.
Would you re-appoint this candidate? If no please give details below.
Do you permit us to discuss this reference with the applicant/client?









Please be sure we have your correct email address in the field above.  Thank you.


Note for referees:

In order to protect the public, the post for which application is being made is exempt from section 4(2) of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. It is not, therefore, in any way contrary to the Act to reveal any information you have concerning convictions which would otherwise be considered ‘spent’ in relation to the application and which you consider relevant to the applicant’s suitability for employment. Any such information will be kept in strict confidence and used only in consideration of the application for this post. Please also note that by completing this reference you grant us permission to present this reference to all clients that request a copy in order to determine applicants’ suitability for each assignment or placement. You also grant permission for this form to be examined by the CQC and the NHS Buying Solutions for auditing purposes.

Thank you in anticipation for completing this form.

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