Reference Request Form

    Name of applicant
    Position applied for
    How long have you known the applicant
    What position/s was the applicant employed with you

    Organisation ability
    Supervisory skills

    Professional Competence

    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
    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 ?

    Other comments relating to suitability

    Referee Name
    Referee’s telephone number
    Referee’s contact details (address) Position