First Name
Last Name
Job Title While Working for you.
Job Title
Email
Company Name Start Date End Date
Company Address
Is the candidate still employed by this company? —Please choose an option—YesNo
Reliability & Punctuality UnsatisfactorySatisfactoryGoodVery GoodExcellent
Honesty & Integrity UnsatisfactorySatisfactoryGoodVery GoodExcellent
Standard of Work UnsatisfactorySatisfactoryGoodVery GoodExcellent
Ability to work with others UnsatisfactorySatisfactoryGoodVery GoodExcellent
Ability to follow instructions UnsatisfactorySatisfactoryGoodVery GoodExcellent
Is this person part of any current disciplinary procedure or investigation?—Please choose an option—YesNo
Subject to company policy would you re-employ this individual?—Please choose an option—YesNo
Do you know of any reason why this applicant would not be suitable to work or have contact with vulnerable people, including children, within a care organization? —Please choose an option—YesNo
Additional Comments
