Reference Request Form (HR-F004)

REFERENCE REQUEST (HR-F004)

Document Ref: HR-F004 (Reference Request)
Version: 1.0
Confidentiality Level: HIGH (Restricted Access - HR/Recruitment)
CQC Alignment: Safe (Safe Staffing) | Well-led (Governance)
Statutory Framework: HSCA 2008 Reg 19 (Fit & Proper Persons) & Schedule 3

SECTION 1: APPLICANT DETAILS

Staff Member Name

Staff_ID

Position Applied For at Mutima Care

Operating Local Authority

SECTION 2: REFEREE DETAILS

Referee Full Name

Company/Organization Name

Referee Job Title

Professional Email Address

Contact Telephone Number

What is/was your working relationship to the applicant?

SECTION 3: EMPLOYMENT VERIFICATION

Applicant's Job Title while in your employment

Employment Start Date

Employment End Date (if applicable)

Reason for Leaving

SECTION 4: SAFEGUARDING & CONDUCT

1. Has the applicant ever been subject to any formal disciplinary action (that is not considered 'spent')?

Please provide details

2. Are you aware of any safeguarding concerns, allegations, or investigations relating to this individual?

Please provide details

3. To the best of your knowledge, is there any reason why this person may be unsuitable to work with vulnerable adults?

Please provide details

SECTION 5: PERFORMANCE APPRAISAL

Honesty, Integrity & Trustworthiness

Reliability & Punctuality

Ability to work effectively in a team

Compassion, Empathy, and Treatment of Others

SECTION 6: FINAL RECOMMENDATION

Would you re-employ this individual?

Please state why

SECTION 7: DECLARATION

Declaration of Truth

Referee Electronic Signature (Full Name)

Date

Next Review Date: