Healthcare Placement Feedback/Reference Form

Your Full Name *

First

Last

Your Job Title *

Your Organisation *

Your Email *

Please provide your organisation email address

Candidate's Full Name *

Candidate's Job Title *

Candidate's Regulatory Body Number i.e. GMC, NMC, HCPC *

Please mark N/A if not regulated i.e. Healthcare Assistants.

Employment Dates (start date) *

Employment Dates (end date) *

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

Please rate the qualities of the applicant named above by selecting the appropriate score

Relationships with patients, other healthcare workers and the public *

Timekeeping and management of workload *

Patient records and other records management *

Reliability *

Character (honest, conscientious, discreet) *

Technical ability *

Communication skills *

Organisational ability *

Professional standards *

Sickness/absence record *

Do you know of any factors concerning the named locum - his/her fitness to practice?

Yes
No

Please specify the clinical duties carried out

Have you had any reasons to instigate disciplinary action concerning the named locum?

Yes
No

Please specify the clinical duties carried out

Any additional comments?

Would you re-employ this candidate?

Yes
No

Your Signature *

By signing above you agree that Athona Ltd can use this placement feedback form as a reference for the above named locum. Please be aware that references will be placed on a candidate's file and as such may be viewed by the candidate under the provisions of the General Data Protection Regulations 2018.

Date Signed *

info@athona.com

01277 217 777

Healthcare Placement Feedback

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Healthcare Recruitment Specialists