Reference Request Form – Caregiver Network

Applicant's Details

Applicant's Name

Charmaine Jambo

Name of Referee

Role(s) Held

Organisation

Start & End Dates

Telephone

Reason for Leaving

How do you know the applicant?

General Character

What are their strengths?

Do you feel there are areas where they could improve?

Yes No

Evaluation of Experience and Performance

Competency	Very Good	Good	Satisfactory	Poor	N/A

Disciplinary & Recommendations

Was disciplinary action taken within the past 12 months?
(If yes, please provide detail.)

Yes No

Was disciplinary action ever taken in relation to their interaction with children, young people or vulnerable adults?
(If yes, please provide detail.)

Yes No

Would you recommend this person as a suitable candidate for a role with Caregiver Network, where they will work with children, young people and vulnerable adults?

Yes No Decline to answer

Would you re-employ this person?

Yes No Decline to answer

Signature & Stamp

Signed

Company
Stamp

Position

Date

Thank you for taking the time to complete this reference. Please be aware that the information you have supplied may be shared with the candidate and that one of our Managers will call you to verify the information above.

Check referee works / worked at the organisation

Verification call via organisation's main switchboard:

Yes No

Email submitted from company email address:

Yes No

Other (give details):

Specific Strengths

Areas for Development

Concerns / Other

I confirm that I have personally verified this reference on behalf of Caregiver Network and recommend the applicant is employed based on the information provided above.

Name

Signature

Role

Date

Reference Submitted