Reference Request Form

Position Applied for

Name of Applicant
Job Applied for
(please refer attached job description)

Nicusor Alexandru Schvartzman

HCA Hospital

Work Location

Emergency hospital-Craiova

Please Outline
Capacity in which you know the Applicant

We worked together in the same department

How long have you known the Applicant?

For more than over 5 years

Job held by Applicant

Dates of Employment
Reason for leaving

Volunteer -HCA
2012-2013
Went for another job

Any current warnings/disciplinary action for performance, attendance or

conduct? If Yes, please provide detail

Yes / No

NO

Have you referred the Applicant to DBS/NMC or any other regularity or

professional body? If Yes, please provide detail

Yes / No

NO

Would you re-employ the candidate? If no, why not?

Yes / No

Yes

Absence whilst in your employment

Sickness
Absence

Applicant has had _1___ episodes of sickness absence in the past three years totalling _1___ days

Parental
Leave

Applicant has taken _10___ days parental leave

Reference Request Form

Rev 01 May2013

Page 1 of 3

Please provide an overview of the applicants key duties & responsibilities whilst in your employment.
He is a good worker, responsible for all the duties and task, punctual , and he always does extra
without being told
His responsibilities were to assist the nurse and the Doctor, to escort service users for x-ray and CTScan, to talk and re-assure them that they will be fine.

Please assess against these performance criteria

Excellent

Competence in the job

Ability to work without supervision

Attitude/ Co-operation

Communication skills (oral & written)

Satisfactory

Variable

Poor

(please expand below)

Professional Conduct

Reliability

Timekeeping
Honesty/Integrity

Good

(please tick() as appropriate)

x
x

Please comment on the candidates suitability for the post (refer attached job description) taking into
account ability, professional and personal characteristics as well as managerial ability, if appropriate,
and any other factors which you consider relevant.

In my opinion seriousity , and the good sense of labour

has its own purpose in every company or organisation,
facts that are not missing to this young gentleman.
He\s a very proefficient worker, ambitious and teamworker. I will defenettly recomand him for the job.

Teamwork is paramount to the successful running of our facilities. In your opinion, has the candidate
ever experienced any problems regarding relationships with others?

He never had any problems working in a team, being a versatile

Reference Request Form
Rev 01 May2013

Page 2 of 3

person and being able to work with all the employees

Please use the space below, to provide any additional information you think may be relevant.
I believe that Mr Schvartzman is going to be one of the best of your employees, and I hope for all his best. If any
future informations are required please do not hesitate to contact me .

In signing this document you agree that the information provided is a) accurate and b) unless you
indicate to the contrary, you consent under the Data Protection Legislation to this information being
disclosed to a third party such as the employee to whom this reference applies.
Please tick () as appropriate.
Name
Company
Position
Date
Signature

Reference Request Form

Rev 01 May2013

I agree

I disagree

Laurentiu Iordachescu
Emergency Hospital Craiova
Nurse Supervisor
13/04/2016
Laurentiu Iordachescu

Page 3 of 3