Beechdale Health Centre

Job Reference Request Template

Document Control

A.Confidentiality Notice

This document and the information contained therein is the property of Beechdale Health Centre.

This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Beechdale Health Centre.

B.Document Details

Classification: / Internal
Author and Role: / Sally Bills- Receptionist
Organisation: / Beechdale Health Centre
Document Reference: / Job Reference Request
Current Version Number: / 1
Current Document Approved By: / Sally Bills
Date Approved: / 04.12.12

C.Document Revision and Approval History

Version / Date / Version Created By: / Version Approved By: / Comments
1 / 04.12.12 / Sally Bills / Sally Bills / Created from default document

Beechdale Health Centre

Swanpool Medical Centre

St. Marks Road

Tipton

West Midlands

DY4 0SZ

0121 557 5310

0121 520 7288

***Insert Date***

R.E. ***Insert Name of Prospective New Employee***

Dear ***Insert Name of Respondent***

The above named person has applied for the position of ***Insert Position*** atBeechdale Health Centre.

They have given us permission to write to you in order to request a reference. We would be grateful if you could please complete the attached questionnaire and return it to us in the enclosed pre-paid envelope at your earliest convenience.

We assure you that all information given will be treated in the strictest of confidence and would like to take the opportunity to thank you in anticipation of your response.

Yours Sincerely

Arun Venugopal (Practice Manager)

Job Reference Request Template

***Insert Name of Prospective New Employee***
Dates employed by you: / From: To:
Length of time known to you
Position(s) held whilst employed by you
Please comment on health / sickness record
Why did this person leave?
Would you re-employ this person?

Please tick the relevant boxes in the table below to indicate your views on performance:

N/A / 1
V poor / 2
Poor / 3
Average / 4
Good / 5
Excellent
Attendance
Timekeeping
Attitude
Flexibility
Honesty
Reliability
Ability to work under pressure
Ability to learn new skills
Use own initiative
Confidentiality
Dealing with the public

Please provide any additional relevant comments overleaf…

Job Reference Request Template

Please sign and date below:

Name:______

Signature:______Position______

Date:______

Doc. Ref – Version – Filename: Job Reference Request TemplatePage 1 of 4