URGENT REFERENCE REQUEST

Please return at your earliest convenience to:

International Reference Co-ordinator
For the attention of: References2@id-medical.com
ID Medical Group Limited,
Unit 2, Mill Square Featherstone Road, Wolverton Mill, Milton
Keynes, England, MK12 5ZD
Tel: 01908 552295 – Fax 01908 810 269

Applicant
Date: Friday, 17 November 2023
Surname:

RGN A&E ITU/HDU Theatre

Applicant Applications HCA RMN Other ………………
Forename: Position:
Band 5 Band 6 Band ………

RGN A&E ITU/HDU Theatre

Position HCA RMN Other ………………
NMC:
Applied For:
Band 5 Band 6 Band ………

Please provide a written clinical reference addressed to ID Medical Group including dates of employment, applicant’s position,
responsibilities and any concerns you may have Or complete the below questionnaire.

The applicant named above has applied to ID Medical Group to be supplied as a locum for the position identified. They have provided
your name and contact details as a referee and we therefore request that you reply to the questions below, providing, in confidence, any
information you are able to or are aware of regarding their character and suitability to perform the role and required duties. Please be
aware the named applicant may request access to the reference under the Freedom of Information Act 2000 and the Data Protection Act
2018 (GDPR).
Please provide the following information regarding the applicant named above:

1. Please State/Confirm the employment dates in which the named applicant worked with you and in what your capacity
was at that time.
From
(please state month MM/YYYY To MM/YYYY At Hospital Name
and year)

Capacity Manager Supervisor Team Leader

(Your Position)
Other Please specify _____________________________________________

2. Do you consider the named applicant suitable for the position identified above?
If no please give details below. Please tick the appropriate box.

Yes ( ) No ( )

3. Do you believe the named applicant to be honest, conscientious, and discreet?

If no please give details below. Please tick the appropriate box.

Yes ( ) No ( )

In order to protect the public, the post for which the application is being made is exempt from Section 4 (2) of the Rehabilitation
of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. It is not therefore in any
way contrary to the Act to reveal any information you may have concerning convictions which would otherwise be considered as
'spent' in relation to this application and which you consider relevant to the applicant's suitability for employment. Any such
information will be kept in strictest confidence and used only in consideration of the suitability of this applicant for a position
where such an exemption is appropriate.

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 Satisfactory
Very Good

Comment
Unable to
Excellent
4. Please tick as appropriate, providing additional comments in support of the

Good
statements made

Poor
Clinical Skills demonstrated in line with the requirements of the position
Patient Records and other records management
Works effectively with colleagues from all disciplines
Communication Skills
Empathy & Sensitivity – takes in patients/colleagues perspectives and treat others with
understanding
Works well under pressure
Supervisory Skills
Organisational Ability, Time Keeping and management of workload

5. Would you re-employ the named applicant? If no, please provide further details below.
Please tick appropriate box

Yes ( ) No ( )

6. Supporting Statement or Written Reference – Please also use this space to let us know of any concerning factors or
outstanding complaints regarding the applicants Clinical Ability that you may be aware of.

By completing this reference you are providing ID Medical with consent to securely keep the reference on file and use this to support the
named applicant’s application with us.
PLEASE KINDLY COMPLETE ALL OF THE FIELDS BELOW

Referee Name Position

Signature HANDWRITTEN Date Signed

Work
Tel No:
E-mail
Hospital Name

Hospital Trust

Hospital Address

IMPORTANT
If you are unable to provide us with a stamp,
please send us a compliment slip/headed paper
with the reference

Your co-operation is much appreciated

HOSPITAL STAMP
ID Medical

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