Employer Reference Request Form
Referee Name:Position:
Name of Organisation:
Please complete this form and return it as soon as possible
Name of Applicant:
Post Applied For:
Please indicate the candidate’s rating on the following:
Punctuality / Attendance: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Attitude to staff / colleagues: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Attitude to clients: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Professional Ability: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Reliability: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Honesty: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Initiative: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Communication skills: / Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ]
Please confirm the applicant’s date of appointment and length of service:
Sickness Absence Record:
a) How many days of absence has this person taken in the last 12 months?
b) Over how many occasions during the year?
c) In your opinion, to what were the absence(s) attributed; i.e. medical complaint, disability, job related, please specify.
Please give details of the applicant’s current/former responsibilities:
Has any disciplinary action ever been taken against the applicant, either on the grounds of conduct or performance?
NO [ ] YES [ ] If ‘YES’ please detail:
If this person has already left or has indicated an intention to leave your employ, please could you indicate the reasons, as far as you are aware.
Have you any reservations about recommending the applicant for future work?
YES [ ] NO [ ]
Would you re-engage / re-employ the applicant? (Please add any further information you feel relevant)
YES [ ] NO [ ]
Are there any other comments you wish to make?
ROLE SPECIFIC QUESTIONS
Taking into consideration the Job Description and Person Specification, can you describe the person’s strengths and weaknesses:
If applicable, please specify any particular knowledge and skills that this person possesses which you think can be directly relevant to this role:
Sign: Date:
Referee Name:
Please tick here if you do not wish this reference to be disclosed to a 3rd party [ ]
Occasionally we will follow up references with a telephone call, can you please provide a contact telephone number:
Company stamp, company compliment slip or business card: / Please return completed form to:
Beverley Hubber
Lifeline Project
15-19 York Place, R24
Edinburgh
EH1 3EB
Date Devised / Aug 14 / Document Control No.
Date Updated / N/A
Date Verified / Version / 002