Name of applicant
Position applied for
How long have you known the applicant
What position/s was the applicant employed with you
What is your opinion regarding the applicant ?
Manner
Organisation ability
Reliability
Supervisory skills
Professional Competence
What is your opinion regarding their relationship with :
Other staff
Patients (if applicable)
Days sick during the last 12 months
Other leave of absence
Would you be willing to re-employ the application YesNo
Have you had any reason to instigate disciplinary action against the applicant ?
Are you aware of any criminal conviction the applicant may have ? The Healthcare Industry is exempt from Rehabilitation of Offenders Legislation therefore, spent convictions are applicable.
Is there any reason why you believe applicant should not work in the community Do you consider the applicant suitable for the position ? YesNo
Other comments relating to suitability
Referee Name
Position
Referee’s telephone number
Referee’s contact details (address) Position
