PRIVATE AND CONFIDENTIAL

R.E.A.C.H LTD
REFERENCE REQUEST FORM

Reference request form in respect of: _______________________________________

Position held whilst in your employment: ____________________________________

Name and Address of organisation/company: ________________________________

________________________________________________________________________

_________________________________________ Postcode: _____________________

Prior to employment with your organisation, did you receive satisfactory references for the
applicant? Yes/No
If the answer is no, please provide further information in the space below:

Your name (who is providing the reference): ____________________________________

In what capacity did you know the applicant/what was your employment relationship:

Manager: Yes/No Other/Specify:

Dates of Service:
Start date: ___________________________ Leaving date: ____________________
Position Held At start: __________________ On Leaving: _____________________

Reason for Leaving, please use the space below:

Main duties and responsibilities please use the space below:

Work Assessment and Performance (Please circle the applicable)

Quality of work Very Good Good Average Poor
Quantity of work Very Good Good Average Poor
Relations with Colleagues Very Good Good Average Poor
Work using initiative Very Good Good Average Poor
Honest/Trustworthy Very Good Good Average Poor
General Conduct Very Good Good Average Poor
Temperament Very Good Good Average Poor
Punctuality/Timekeeping Very Good Good Average Poor
Interpersonal Skills Very Good Good Average Poor
Attendance Very Good Good Average Poor

Sick leave during preceding 2 years: No of Days: ___________________________

No of instances: ________________________

Has the applicant been involved in any disciplinary hearing, if so what was the reason and what
was the outcome? Yes/No

EMPLOYMENT REFERENCE 1
 PRIVATE AND CONFIDENTIAL
If yes please detail in the space below:

Is there any disciplinary action pending against the applicant? Yes/No

If yes, please provide details in the space below:

Would you re-employ the applicant? Yes/No

If no, please provide your reason in the space below:

Are you aware of any reasons why the applicant should not be employed to support adults with
learning disabilities? Yes/No
If Yes, please give your reason in the space below:

Due to the nature of employment this post is exempt from section 4(2) of the provision of the
Rehabilitation of Offenders Act 1974 and it will in no way contravene the Act to disclose
information which you may have in connection with this applicant regarding any convictions which
would otherwise be considered spent.

Have you carried out a CRB check on the applicant? Yes/No

If yes, please give details of the outcome in the space below; list any convictions you are aware of:

Have you referred the applicant to be listed on the PoVA/PoCA or ISA list? Yes/No
If yes, please give details below:

Please state in your opinion the applicants suitability for this position :(please refer to the enclosed
Job description and Person specification)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please list-using space below:

Applicants’ strengths: Applicants weaknesses:

This reference was completed by:

Name: ____________________________ Position: _________________________

I confirm that I am authorised to provide the reference for and on behalf of the Company

Signature: ________________________ Date: ____________________________

Company Stamp on Reference/Headed Paper or Compliment Slip acceptable

Work telephone number: ________________ Mobile: ________________________

EMPLOYMENT REFERENCE 2