Reference Form
Reference Request For*
Your Name & Position*
Company Name*
Contact Number*
Email*
Employment Details
Date Employed From*
Day Month Year
Date Employed To*
Day Month Year
Candidate Job Title*
Reason For Leaving*
Would You Re-employ*
Comments/Further Information
Behavioural
General Conduct*
Excellent Good Satisfactory Poor
Timekeeping*
Excellent Good Satisfactory Poor
Communication Skills*
Excellent Good Satisfactory Poor
Relationship With Colleagues*
Excellent Good Satisfactory Poor
Relationship With Patients*
Excellent Good Satisfactory Poor
Level of Performance*
Excellent Good Satisfactory Poor
Additional comments. If you ticked satisfactory or poor for any of the above please provide further information
Has the candidate's honesty and integrity ever been brought info question that you are aware of? (Please comment)*
Do you consider the candidate to need Clinical or Behavioural Development?*
Are you aware of any GDC proceedings, PCT investigations or disciplinary action?*
I declare that to the best of my knowledge the information I have given is correct*
I Agree
Genix Healthcare Ltd
2 College Court
Gildersome
LS27 7WF
Tel: 0845 838 1122
Should be Empty: