Registered Company No.
6107910
CONFIDENTIAL REFERENCE REQUEST
UNLESS YOU INDICATE TO THE CONTRARY,
THE CONTENTS OF THIS REFERENCE MAY BE DISCUSSED WITH THE APPLICANT
CANDIDATE DETAILS
Candidate Name: Samuel Chijioke Ohaezu
Candidate DOB: 21/05/2000
Position Applied For: Healthcare Assistant
REFEREE DETAILS
Name of Referee Michael Klinn
Job Title: Manager
Organisation: The Sage
Telephone Number: 07859808712
Relationship To Candidate: Senior
EMPLOYMENT DETAILS
Please confirm the below details regarding the named applicant above:
Position held within your company: Cleaner
Dates of Employment 11/11/2022-20/01/2023
How long have you known the individual and in what
2 Months
capacity?
APPLICANT DETAILS
Why did the applicant leave your employment, if
applicable?
Standard of Performance (please circle response): Excellent / Good / Satisfactory / Poor
Additional Comments:
Honesty (please circle response): Excellent / Good / Satisfactory / Poor
Additional Comments:
Punctuality (please circle response): Excellent / Good / Satisfactory / Poor
Additional Comments:
Conduct (please circle response): Excellent / Good / Satisfactory / Poor
Additional Comments:
Relationship with others (please circle response): Excellent / Good / Satisfactory / Poor
Team Members (please circle response): Excellent / Good / Satisfactory / Poor
Managers (please circle response): Excellent / Good / Satisfactory / Poor
Additional Comments:
ADDITIONAL DETAILS
Please use this space to indicate
whether you are satisfied that the
person has the ability and is suitable to
undertake this job as indicated in the
person specification. Please comment
on the applicant’s suitability for the post
and demonstrate how they meet the
person specification commenting on the
areas of required knowledge,
experience, skills and abilities,
Has the individual been subject to
capability procedures within the last 2 Yes / No
years?
If yes, please provide details of the
concerns which gave rise to this, the
duration of the proceedings and the
outcomes.
Did/has the individual been subject to a
disciplinary procedure (e.g. formal
warning, demotion, redeployment due
Yes / No
to misconduct or dismissal) whilst in
employment with yourselves (please
circle response)?
If yes, please provide details of any
disciplinary record even if any action is
now considered expired for disciplinary
purposes. Please state if the candidate
was found guilty of dishonesty and/or
breach of trust:
Is/has the individual ever been subject
to an Employment Tribunal or Yes / No
Employment Appeal Tribunal?
If yes, please provide details (including
the nature of the candidate’s
involvement):
To your knowledge has the applicant
ever been convicted of a criminal Yes / No
offence?
If yes, please provide details:
Has the applicant been charged with a
criminal offence or are criminal charges Yes / No
against him/her pending?
If yes, please provide details:
Has the applicant been the subject of
any child/vulnerable adult protection Yes / No
concerns?
If yes, please provide details of any
enquiry:
RE-EMPLOYMENT
Are you aware of any justifiable reason
why we should not employ him/her or of
any reason why he/she should be Yes / No
considered unsuitable to work with
children?
If yes, please state your reasons:
DECLARATION
I declare to the best of my knowledge that the information provided within this reference is factually correct
NAME:
SIGNATURE:
DATE:
Company Stamp:
Please return this form to: Primary Care Recruitment Ltd, 10 Lansdowne Terrace, Gosforth, Newcastle Upon
Tyne NE3 1HN.
Office Use Only; I can now confirm that I have done the correct checks by checking the establishment
online and calling the above referee on a landline number to ensure that the referee works there.
Reference accepted by:
NAME:
Job Position:
SIGNATURE:
DATE:
0191 284 7001
[email protected]www.primarycarerecruitment.co.u
