PROFESSIONAL REFERENCE REQUEST FORM

Name and Address of company supplying details

In what Capacity did you know the applicant?

Dates of employment if any

Position on leaving the company

Honesty

Efficiency

Trustworthy

Caring

Competence

Reliability

Time Keeping

Able To Communicate

Relationship With Other Staff

Relationship With Clients/Service Users

Conduct

Skills

Sickness Record

Are you aware of any health problems that may affect applicant working in a social care environment?

Yes No

If yes, please give details:

Do you know of any reason why this applicant should not engage in a social care setting?

Yes No

If yes please give details:

Please note, all information submitted to Profad Care Agency will be held in strictest confidence, in accordance with the Data Protection Act (Revised 1998)

The reference you provide us with may need to be passed to a subsequent employer in line with the Care Standards Act 2000. If you do not wish any of the information you have supplied to be passed to any prospective employer, please tick box

In line with the Data Protection Act, if you do not wish for any information you have supplied to be passed to the worker, please tick the box

Are you aware of any previous convictions (spent or otherwise) that this applicant may have?

Yes No

If yes please give details:

Please outline duties and responsibilities in the post held:

Was the employee subject to any formal disciplinary/suspension or dismissal at the time he or she left your employment?

Yes No

If Yes, please comment:

Does the employee have any unexpired formal warnings i.e. verbal, written or final written warnings on his or her record? If so, please give details below:

Would you re-employ this person?

Yes No

Please comment on any other information/ observations you consider relevant:

If you would like more information on Profad Care Agency, please tick box

Name and Address of company supplying details

In what Capacity did you know the applicant?

Dates of employment if any

Position on leaving the company

Honesty

Efficiency

Trustworthy

Caring

Competence

Reliability

Time Keeping

Able To Communicate

Relationship With Other Staff

Relationship With Clients/Service Users

Conduct

Skills

Sickness Record

Are you aware of any health problems that may affect applicant working in a social care environment?

Yes No

If yes, please give details:

Do you know of any reason why this applicant should not engage in a social care setting?

Yes No

If yes please give details:

Please note, all information submitted to Profad Care Agency will be held in strictest confidence, in accordance with the Data Protection Act (Revised 1998)

In line with the Data Protection Act, if you do not wish for any information you have supplied to be passed to the worker, please tick the box

Are you aware of any previous convictions (spent or otherwise) that this applicant may have?

Yes No

If yes please give details:

Please outline duties and responsibilities in the post held:

Was the employee subject to any formal disciplinary/suspension or dismissal at the time he or she left your employment?

Yes No

If Yes, please comment:

Does the employee have any unexpired formal warnings i.e. verbal, written or final written warnings on his or her record? If so, please give details below:

Would you re-employ this person?

Yes No

Please comment on any other information/ observations you consider relevant:

If you would like more information on Profad Care Agency, please tick box