Professional Reference – Support Worker/Healthcare Assistant

Applicant name *

Applicant Job Title

Job title *

Specific dates of employment: (Please use exact dates) *

Reason for leaving employment? If dismissed please supply details: *

Was applicant honest and trustworthy at all times? Yes No If no please supply full details: *

During employment was applicant the subject of a Disciplinary procedure? Yes No If yes, please supply full details and outcome *

Would you re-employ applicant? If no, please state reasons why: *

Do you have any other information you feel would be relevant to an employer? *

General Conduct *ExcellentGoodSatisfactoryBelow AveragePoor

Work Performance *ExcellentGoodSatisfactoryBelow AveragePoor

Attitude to Work *ExcellentGoodSatisfactoryBelow AveragePoor

Initiative *ExcellentGoodSatisfactoryBelow AveragePoor

Time Keeping *ExcellentGoodSatisfactoryBelow AveragePoor

Relationships with colleagues *ExcellentGoodSatisfactoryBelow AveragePoor

Relationships with customers: *ExcellentGoodSatisfactoryBelow AveragePoor

If you indicated applicant is “Below Average” or “Poor” for any category please state your reasons below:

Signature *Print Name

Position Held *

Company name *

Phone *

Email Address *

Company Address *

City *

State/Province

ZIP / Postal Code *

Country

Date

Samaras Healthcare Recruitment Ltd

61 Bridge Street
Kington
Herefordshire
United Kingdom
HR5 3DJ

Company number 13231677

Open: Monday to Friday 9:30am to 5:00pm