Reference Request Form - Healthcare Jobs

If you are human, leave this field blank.

Applicants Name

GMC/NMC/HCPC Number

Position Applied For:

Please state the nature and capacity of your acquaintance to the named applicant

Clinical Director

Consultant

Direct Line Manager

OtherOther

How long did the named applicant work for/with you or under your supervision and in what capacity, i.e. clinical position/grade and specialty? *

Start Date

If you are unsure of start and end DAY please use the 1st

End Date

Do you believe the named applicant to be honest, conscientious and discreet? If no, please provide further details below Do you believe the named applicant to be honest, conscientious and discreet? If no, please provide further details below

Do you know of any factors concerning the named applicant which might cause his/her fitness for employment or reasons why the named applicant should not work in a clinical environment? If yes, please provide details below. Do you know of any factors concerning the named applicant which might cause his/her fitness for employment or reasons why the named applicant should not work in a clinical environment? If yes, please provide details below.

Have you had any reasons to instigate disciplinary action against the named applicant? If yes, please provide details below. Have you had any reasons to instigate disciplinary action against the named applicant? If yes, please provide details below.

Do you consider the named applicant suitable for the position identified above? If no, please provide further details below. Do you consider the named applicant suitable for the position identified above? If no, please provide further details below.

Would you re-employ the named applicant? If no, please provide further details below. Would you re-employ the named applicant? If no, please provide further details below.

Please provide any further information which is relevant to above named applicant’s application to be supplied as a locum in the position identified above?

Address

Hospital or Organisation Name

Address

City/Town

County

Post Code

Country

Email Address *

CANNOT BE A PERSONAL EMAIL ADDRESS

Phone Number *

Must be a number we can contact you on

Date