1. Please provide details of your organisation and the person you are referencing:
Your Organisation (required)Your Name (required) Your Job Title (required) Candidate's Name (required)Candidate's Job Title (required)
2. Please provide dates of employment: From(required)To (required)
3. Why did /does the applicant leave/wish to leave your organisation?
4. Are you related to the applicant in any way? Yes / No. If yes, please give details
5. In the applicants last two years of employment with you: How many days of sickness absence did they take? (required) How many periods of sickness absence did they have? (required)
6. Does the applicant have any disciplinary actions on their file or are they subject to an investigation or disciplinary hearing? If yes, please give details.
7. Would you re-employ the applicant? If no, please explain YesNo If no, please explain your reasons
8. Please rate the applicant on these and add any comments as appropriate in the box below. Learns from situations and past experience PoorAdequateGoodExcellentUnable to comment
Plans, structures and prioritises own work PoorAdequateGoodExcellentUnable to comment
Communicates effectively PoorAdequateGoodExcellentUnable to comment
Teamwork PoorAdequateGoodExcellentUnable to comment
Provides assistance when required PoorAdequateGoodExcellentUnable to comment
Problem Solving PoorAdequateGoodExcellentUnable to comment
Involves others in decision making affecting them PoorAdequateGoodExcellentUnable to comment
Developing Own Capability PoorAdequateGoodExcellentUnable to comment
Meeting Clients Needs PoorAdequateGoodExcellentUnable to comment
Seeks ideas for improvement PoorAdequateGoodExcellentUnable to comment
Refers problems upwards when appropriate PoorAdequateGoodExcellentUnable to comment
Managing Own Work PoorAdequateGoodExcellentUnable to comment
Works hard to achieve objectives and goals PoorAdequateGoodExcellentUnable to comment
Resilient under pressure PoorAdequateGoodExcellentUnable to comment
Flexible and open to new ways of working PoorAdequateGoodExcellentUnable to comment
9. Do you have any other relevant comments you wish to make regarding the applicant?
* 10. Are you happy for us to show the candidate a copy of this reference: Yes No
