Reference Form

Your name has been provided by the applicant name above,

who has applied to Brit Locums Limited to be supplied as an
Agency Worker in the locum position. Please provide the
following information regarding the applicant and tick the
appropriate box. Please return the form to us via your
professional email address or accompany it with Organisation
stamp for his form to be deemed valid.
Organisation stamp

Candidates Name and Surname:

Candidates Job Title and Band:
Referee Name and Surname:
Referee Job Title and Band:
Hospital / Clinic / Organisation:
Ward type:
Contact number:
Dates worked from: Dates worked to:
(MM & YYYY) (MM & YYYY)

Would you re-employ / offer locum work to this person? YES NO

Skill / Rating Excellent Very Good Good Satisfactory

Suitability to Role ☐ ☐ ☐ ☒
Knowledge ☐ ☐ ☐ ☐
Ability to work under pressure ☐ ☐ ☐ ☐
Interpersonal Skills ☐ ☐ ☐ ☐
Time-keeping ☐ ☐ ☐ ☐
Consultation skills (e.g. patient feedback) ☐ ☐ ☐ ☐
Co-operation with other staff ☐ ☐ ☐ ☐
Presentation ☐ ☐ ☐ ☐
Trustworthiness ☐ ☐ ☐ ☐
Reliability ☐ ☐ ☐ ☐
Computer Skills ☐ ☐ ☐ ☐
Please articulate your reference in more detail below:

Print Name and Surname:

Signature:
Date:

V082022 Brit Locums Ltd

108 Cranbrook, Ilford IG1 4LZ LONDON
[T] 0207 265 9382 [E] admin@britlocums.co.uk.