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Name of Referee

Name of Organisation

Position in 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:

DATES OF EMPLOYMENT: (start


and finish)

How long have you known the applicant 1 year or less 1 to 3 years 3+ years

How do you know the applicant (professional capacity) Colleague Supervisor Manager

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

Please give details of this candidates start date and finish date month and year:

Sickness number of days : 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, why not)

Any other comments

Date_______________ Signed ______________________________

Position___________________________________ Sealed

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.