Name of Referee
Name of Organisation
Position held within your
Organisation
This person has given your name as a reference in their application. I would be most grateful if you would complete the
questions below and return to me by email.
APPLICANT (Name of candidate):
POSITION APPLIED FOR: Radiographer
DATES OF EMPLOYMENT: (start and
finish, please include month and year)
How do you know the applicant (professional capacity) Supervisor Manager Senior Doctor /
Please note colleagues cannot provide a reference, you must be a direct Consultant
supervisor.
What is your opinion of the applicant character with regard to:
Excellent Good Fair Poor
Honesty
Reliability
General Conduct
Professional/Technical competence
Ability to accept responsibility
Communication Skills
• Sick Leave - number of days taken per year: Number of Occasions:
• Is the applicant subject to/or have they had any disciplinary action against them? Yes / No
• From your knowledge, which category would you place her/him in relation to the post applied for?
Excellent Very Good Good Fair Poor
• Would you employ this individual again? Yes / No
If not, please provide details/reason:
• Any other comments
Date: _ _ Seal/Company Stamp:
Signature: _ _ _ _ _
Thank you for your assistance in this matter.
Please make sure that you use your hospital stamp / Seal or copy and paste onto headed paper.