Doctors Reference Form

Applicant's Details

Candidate's Name*

First Name Last Name

Candidate Reference*

In what capacity did you know the named applicant?*

When did you meet the named applicant?*

What skills and experiences has the applicant demonstrated that may be regarded as valuable attributes for position they’re applying for?*

Referee's Details

Name*

First Name Last Name

Phone Number*

Email*

Referee's Profession*

Please state profession*

Declarations

I the undersigned hereby declare that the information I have given in this reference is true to the best of my knowledge and belief*

Yes

Referee's Signature*

Date*

Please be aware that the person for whom we are requesting the reference for may request access to it under the Freedom of Information Act 2000 and the Data Protection Act 2018 (GDPR). This information is required to comply with our obligations to provide a suitable reference. The information will be held securely and only shared with 3rd parties requiring the reference details.

Position Held During Employment

Hospital name*

Grade*

Speciality*

Can you confirm that as a Consultant, the named applicant worked under 'Supervision, Direction, and Control'?*

Did work under 'Supervision, Direction, and Control'
Did not work under 'Supervision, Direction, and Control'

Start Date*

Please refer to email

Is the applicant currently still in post?*

Yes
No

End Date*

Please refer to email

Has the applicant worked additional dates at this hospital?*

Yes
No

Please list dates ( in MM/YYYY format), positions and details below

Do you consider the named applicant suitable for the position identified above?*

Yes
No

If no, please give details below*

Do you believe the named applicant to be honest, conscientious and discreet?*

Yes
No

If no, please give details below*

Please select from the dropdowns below as appropriate

Clinical skills demonstrated in line with the requirements of the position*

Patient records and other records management*

Works effectively with colleagues from all disciplines*

Communication skills*

Empathy & sensitivity*

Works well under pressure*

Supervisory skills*

Time keeping and organisational ability*

Are you aware of any concerning factors or outstanding complaints regarding the applicants Clinical Ability that you may be aware of?*

Yes
No

If yes, please give details below*

Would you re-employ the named applicant?*

Yes
No
N/A

If no, please give details below*

Please provide relevant comments to support the reference*

Referee's Information

Full Name*

First Name Last Name

Position*

Relationship to applicant?*

If other, please give details*

Hospital Name*

Phone Number*

Email*

Declarations

In order to protect the public, the post for which the application is being made is exempt from Section 4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. It is not therefore in any way contrary to the Act to reveal any information you may have concerning convictions which would otherwise be considered as 'spent' in relation to this application and which you consider relevant to the applicant's suitability for employment. Any such information will be kept in strictest confidence and used only in consideration of the suitability of this applicant for a position where such an exemption is appropriate.

I the undersigned hereby declare that the information I have given in this confirmation of employment is true to the best of my knowledge and belief*

Yes

Referee's signature*

Date*

Please be aware that the person for whom we are requesting the reference for may request access to it under the Freedom of Information Act 2000 and the Data Protection Act 2018 (GDPR). This information is required to comply with our obligations to provide a suitable reference. The information will be held securely and only shared with 3rd parties requiring the reference details.