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info@bankplusrecruitmentandtraining.co.uk
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info@bankplusrecruitmentandtraining.co.uk
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Reference form
"
*
" indicates required fields
EMAIL
*
Referee Name
*
SURNAME
FIRST NAME
Contact Number
*
REFERENCE REQUEST
Dear Sir/Ma, The above-named person has applied for registration with Bankplus Recruiting and Training Ltd for the role of Healthcare Assistant and has given your name as a referee. Please complete this reference request.
Organisation/Employer
*
Position held by candidate
*
Employed from
MM slash DD slash YYYY
Employed To
MM slash DD slash YYYY
Personal Competency
Check all that apply
Professional Competency
Excellent
Good
Average
Just acceptable
Not acceptable
Reliability
Excellent
Good
Average
Just acceptable
Not acceptable
Timekeeping/ Attendance
Excellent
Good
Average
Just acceptable
Not acceptable
Honesty
Excellent
Good
Average
Just acceptable
Not acceptable
Attitude
Excellent
Good
Average
Just acceptable
Not acceptable
Flexibility
Excellent
Good
Average
Just acceptable
Not acceptable
Ability to work in a team
Excellent
Good
Average
Just acceptable
Not acceptable
Do you consider the applicant to be a suitable person to work with?
Mark only one oval per row
The elderly
YES
NO
Children
YES
NO
Physically disabled
YES
NO
Persons with mental health problems
YES
NO
Bathing/Shower/Strip Wash
Please complete only if the applicant has experience in care work.
Personal Hygiene:
Mark only one oval per row.
Bathing/Shower /Strip Wash
YES
NO
Bed Bath
YES
NO
Dressing/Undressing
YES
NO
Use of Bath Sides
YES
NO
Shaving
YES
NO
Mouth care
YES
NO
Care Of Feet
YES
NO
Care of hair
YES
NO
Care of eyes
YES
NO
Care of fingernails
YES
NO
Toileting:
Mark only one oval per row
Applying a Convene
YES
NO
Attaching a Right Bag
YES
NO
Changing a Catheter Bag Emptying a Catheter Bag
YES
NO
Bedpans/Commode
YES
NO
Stomach Care
YES
NO
Convenience care
YES
NO
Mobility:
Mark only one oval per row
Moving and handling course
YES
NO
Use of hoists (manual/electrical)
YES
NO
Care Duties:
Mark only one oval per row
Assisting with medication
YES
NO
Row 2
YES
NO
Sample dressing procedures
YES
NO
terminal care
YES
NO
Practical Tasks
Mark only one oval per row
Bed making/changing beds
YES
NO
Light housework
YES
NO
Cooking
YES
NO
Collecting Benefits
YES
NO
Shopping
YES
NO
Laundry
YES
NO
Nutrition
Mark only one oval per row
Feeding
YES
NO
Preparing meals
YES
NO
Food Handling
YES
NO
Relationship with clients/service users (please comment):
*
In your opinion, is this person suitable for health care agency work?
*
Mark only one oval.
Yes
No
Would you re-employ this person in the same capacity in the future? If NO, please give details.
*
Mark only one oval.
Yes
No
If NO, please give details.
*
Do you know of any reason why we should not employ this person? If ‘Yes’ please give details.
*
Mark only one oval.
Yes
No
If YES, please give details.
*
Do you know of any formal or informal disciplinary action taken against this person? If ‘Yes’ please give details.
*
Mark only one oval.
Yes
No
If YES, please give details.
*
Do you know of any formal or informal disciplinary action taken against this person?
*
We will show this reference to the candidate if requested. If you would prefer us to withhold this reference, please tick to withhold.
Check all that apply.
Tick to withhold
Signature
*
