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The document is an employment reference form for Central Park Nursing Home, requesting information about an applicant's work history, skills, and any disciplinary actions. It includes sections for the referee to provide their relationship with the applicant, performance evaluations, and personal qualities. The form must be signed and stamped to be considered valid.

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2 views2 pages

Form

The document is an employment reference form for Central Park Nursing Home, requesting information about an applicant's work history, skills, and any disciplinary actions. It includes sections for the referee to provide their relationship with the applicant, performance evaluations, and personal qualities. The form must be signed and stamped to be considered valid.

Uploaded by

ezclownc
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Central Park Nursing Home

EMPLOYMENT REFERENCE FORM


Applicant’s Name:

Position Applied for:

How long have you known the applicant and in what capacity?

Tick here if you are / have been the applicants direct Line Manager
If the applicant is / was employed by you or your organisation, what was their:

Start Date: End Date:

Last Position Held: Reason for leaving: Went to College


Customer Advisor Other Employment
Further Training
End of Fixed Term Contract
Dismissal
Other
Does this person on file currently have any disciplinary sanctions against them?
If so, please give details:

Do you know of any cautions, criminal convictions, warnings or reprimands in respect of


the applicant? (Please note any information disclosed will be dealt with in the strictest
confidence)

Please state the number of days and episodes of sickness absence the applicant has had
in the past two years:
Number of Days:__________ Number of Occasions:_________

Given the opportunity, would you re-employ the applicant?


If no, please give details:

For the criteria below, please tick one box for each row that applies:

Very Below
Professional Skills / Experience Good Average
Good Average
Knowledge
Expertise & Ability
Communication Skills
Personal Organisational Skills

SC 3 - Reference Request
June 2013
Very Below
Personal Qualities Good Average
Good Average
Ability to deal sensitively and politely with public,
patients and / or colleagues
Standard and quality of work
Trustworthy
Flexibility
Seeks help appropriately
Commitment to Learning

Very Below
Attitude to work and/or Training Good Average
Good Average
Contribution to the Team / Department
Ability to meet deadlines
Ability to work under pressure
Ability to work on own initiative
Willingness to learn
Timekeeping
Reliability

Please summarise your experience of the candidate:

Do you have any objections to the applicant having sight of this reference?

Company stamp:
Name of Referee:
This reference will not be considered valid
unless endorsed with an official stamp or,
Job Title: …………………….…………………… alternatively, a compliment slip / official
headed paper is attached.
E-mail: ……………………………………………

Telephone No: ………………………………….

This reference has been provided without


prejudice and is correct to the best of my
knowledge and belief:
Signature: ……………………………………….
Date: …………..………………………………….
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM

SC 3 - Reference Request
June 2013

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