Reference Request Form - Independent Living Lancashire

Applicants details

Name:

Position applied for:

Information about the applicant

Type of reference:

Relationship to the applicant:

Position within the organisation:

Reason for leaving:

Length of employment, from:

Length of employment, to:

Please comment on the appropiate area by selecting an option

Communication skills:

Attendance and punctuality:

Attitude to others:

Attitude to job:

Reliability and honesty:

Working as part of a team:

Working alone:

Planning and co-ordination:

Dependability:

Recording skills:

Trustworthiness:

Confidentiality:

Observations:

Quality of work:

Personal appearance:

Do you feel this person is suitable for the position they are applying for?

Please comment:

Other information

Days off work due to sickness within the last 12 months:

Any other abscences within the last 12 months:

Are you aware of any disciplinary action:

If yes, please give details:

Has a recent criminal records check been undertaken with the DBS:

If yes, please give details:

Are you aware of any criminal matters that could affect this person’s suitability of employment:

If yes, please give details:

The role of a care assistant can be quite a physical role including lifting, moving and some walking may be involved. In your opinion do you think the applicant is physically fit and well to carry out this role:

If no, please give details:

What do you think the applicant’s main strengths/ weaknesses are:

Would you re employ this person:

If no, please give details:

Declaration

I confirm that all the information given is correct to the best of my knowledge

Name:

Signature:

Company:

Address:

Number:

Date: