Remity Staffing – Nurses Reference Form

Remity Staffing - Nurses Reference Form

Nurses Reference Form

Applicant name*

Date of birth*

Position Applied for*

NMC Pin Number*

Dates Applicant Worked (Start Date)*

Speciality / Department Worked for*

End Date*

Please tick to confirm dates provided are correct *

Ability to work as part of a team

Clinical Skills Competency

Ability to apply appropriate nursing skills

Ability to record & monitor Hospital Early Warning Scoring System

Ability to communicate well with patients and other team members

Ability to check Blood pressure, Temperature, Pulse, respiration, Oxygen Saturations, BM

What was your professional relationship to the applicant?*

Please list any training the applicant attended whilst in your employment?*

Was the applicant ever subject to disciplinary proceedings whilst in your employment

If you have ticked yes please give details

What was the applicant’s reason for leaving this employment?*

Please state the total number of days sickness absence the applicant took in the last twelve months of this employment and on how many separate occasions they were absent*

Would you or your organisation re-employ this applicant for a similar role? Please enter Yes or No - if you have ticked NO then please give details below*

Were there any concerns at any time about the applicant’s professionalism or conduct? Please enter Yes or No - if you have ticked NO then please give details below*

Please make any additional comments regarding the applicant’s suitability for work in the care industry in the box below, using extra sheets if necessary.

By virtue of the Rehabilitation Of Offenders Act 1974 (Exceptions Order 1975) this post is exempt from section 4(2) of the Rehabilitation of Offenders Act 1974. Please list any information regarding criminal convictions the applicant may have which may be relevant to the position applied for. All information given will be treated in the strictest confidence.