REFERENCE QUESTIONNAIRE

The person you know has applied to us for the post of Support Worker and will be working in services within the community, supporting adults with learning disabilities and needs that challenge. They have given your name as a person to whom a reference may be made.

Please bear in mind the fact that the applicant will be employed in the services of vulnerable people, and we particularly need to know whether you are aware of any impediment that may render them unsuitable for this type of work.

We would be very grateful if you would complete the below questionnaire at your earliest opportunity. Your responses will be treated in the strictest confidence.

Details
Name of Applicant

Previous Employment

Previous Position

Dates of Employment

Reason for Leaving

How long have you known the applicant?

Please give brief details of duties and responsibilities

Would you re-employ the applicant?

During employment, did the applicant suffer any serious injury or recurring symptoms or illness?

Did the applicant suffer from any of the following whilst in your employment?
Bronchitis

Angina

Back pain

Hearing trouble

Sight problems

Alcoholism / drug dependency

Other - please specify

Was the applicant, to the best of your knowledge dependant on drugs or medication?

Do you consider the applicant to be?
Reliable

Puntual

Trustworthy

Approachable

Tactful / Respectful

Discreet

Self-motivated

Please rate the following
Attitude towards colleagues

Attitude towards supervisors

Their understanding of Health and Safety responsibility

Bearing in mind that the applicant may have to deal with emergency situations, how would you rate their level of
Competence

Common sense

Do you consider the applicant relates well / would relate well with clients in his / her care?

Attendance
Record of attendance

Number of sick days in the last 12 months

Number of ocassions:

What was the applicant's sick record like?

Was a discussion ever held about the applicant's sickness record?

Rehabilitation of Offenders Act
This position is exempt from the Rehabilitation of Offenders Act 1974, and any convictions must be declared.

Are you aware of any convictions held by the applicant?

Are there any issues or investigations pending?

Would you like to make any other comments about the applicant's suitability for this position?

Thank you
Thank you for your assistance in the above person’s application. It has been appreciated. The position applied for is reserved for the applicant subject to your reference being submitted.

Name

Telephone

Organisation Name

Position held in company

Date

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