Serenity Always Healthcare Reference request Form
Name of Individual*
Position Applied For at Serenity Always Healthcare*
Name of Company / Organisation*
Name of Referee*
Job Title of Referee*
How is individual known to you?*
Date employment commenced*
Date employment ended*
Job title of individual*
Annual Salary:*
Reason for leaving*
Number of sickness absence days in last 12 months of employment*
Would you re-employ this individual?*
—Please choose an option—NoYes
Please provide further details*
Has the individual been referred to the Disclosure and Barring Service on the grounds of misconduct which has harmed or caused risk of harm to a vulnerable adult?*
Is the individual or their practice in relation to safeguarding vulnerable adults, currently under question by any formal procedures?*
Do you know of any reason why the individual should not work with vulnerable adults?*
Was the individual subject to any disciplinary sanctions / performance management within the last 24 months? ?*
Please comment on the individual's personal qualities as follows:
Productivity
—Please choose an option—ExcellentGoodPoor
Self-motivation
Honesty
Time keeping / Punctuality
Flexibility
Communication
Reliability
Team working
Any further details
Sign
Full Name*
Date*
