REFERENCE REQUEST: HomeCarehc-1

Date

Dear

Re:

The above named applicant has applied to Concept Care Solutions for the position of Domiciliary Care
Worker and has given your name as someone whom we may contact for a reference.

Please assist us by providing us with information to enable us to access this candidate’s capability and
suitability.

Your reply, including any information given to us, will be treated in the strictest confidence.

We would like to thank you in advance for your assistance in this matter.

Yours sincerely

Concept Care Solutions

Southend Branch
92 Rectory Grove
Leigh on Sea
Essex SS9 2HL
01702567430
Date:
Name:
Position:
Email :
Tel:

Re:
Position
Care Assistant
applied for:

Your name has been provided by the applicant named above, who has applied to Concept Care
Solutions to be supplied as a locum in the position identified above. We would be grateful if you would
reply to the following questions regarding this applicant and provide in confidence any information
which you are able to/aware regarding his/her character and suitability to the perform the role and
associated duties of the position applied for.

Please provide the following information regarding the applicant named above:

1. How long did the named applicant work for/with you or under your supervision and in what
capacity, Job title, band?

From To
Capacity

2. Please state the nature and depth of your acquaintance to the named applicant?

3. Do you believe the named applicant to be honest, conscientious and discreet? If no, please
provide further details below. Please tick the appropriate box.

Yes No
4. General performance of the named applicant:

Satisfacto
Unable to

Excellent
comment

Good

Good
Very
Poor
Please  as appropriate, providing additional comments in support

ry
of the statements made

Quality of work
Ability to work on own initiative/and under
pressure
Team working skills
Time keeping/flexibility
Reliability
Communication skills
Honesty/integrity
Relations with others
Sickness/absence record
Additional comments in support of the statements made

5. 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. Please tick the appropriate box.

Yes No

6. Are you aware of any criminal conviction(s) relating to the named applicant? If yes, please
provide details below. Please tick the appropriate box.

Yes No
7. Have you had any reasons to instigate disciplinary action against the named applicant? If yes,
please provide details below. Please tick the appropriate box.

Yes No

8. Has the named applicant been or is currently the subject of any fitness to practice proceedings
by an appropriate licensing or regulatory body in the United Kingdom or any other country? If
yes, please provide details below. Please tick the appropriate box.

Yes No

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

Yes No

10. Would you re-employ the named applicant? If no, please provide further details below. Please tick
the appropriate box.

Yes No
 11. 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?

In order to protect the public, the post for which the application is being made is exempt from Section
4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974
(Exceptions) Order 1975. It is not therefore in any way contrary to the Act to reveal any information
you may have concerning convictions which would otherwise be considered as 'spent' in relation to
this application and which you consider relevant to the applicant's suitability for employment. Any such
information will be kept in strictest confidence and used only in consideration of the suitability of this
applicant for a position where such an exemption is appropriate.

Reference Request completed by:

Referee name Position

Signature Date
Tel. no Email

Organisation Name &

Address

Company Stamp
If you are unable to
provide a company
stamp, can you
please return the
reference with a
signed compliment
slip, letter headed
paper or via
Company email.

PLEASE NOTE
 If you are unable to provide a company stamp, can you please return the reference with a signed
compliment slip, letter headed paper or via Company email.
 The information disclosed in this reference may be shared with our clients and for auditing purposes, upon
request.
 Information disclosed in this reference will not be passed on to the candidate without prior authorisation.