Applicants Full Name (required)

Please provide your reference below

The applicant has applied for a position with Quality Home Care and has given your name for reference purposes.

I would be grateful if you could complete the form below, as confirmation of employment to ensure timely recruitment. If you are not a current or previous employer please complete section 8 onwards.

Please note that under the Data Protection Act of 1998 and Freedom of Information Act 2000, candidates may request access to any information that is held on them. The data requested is exclusively for the purpose of recruitment. Information disclosed must not be passed to anyone who is not authorised to have this information.

May I take this opportunity to thank you in anticipation of your assistance.

1) Please confirm employment dates

2) Please confirm the applicant's current/most recent job title and grade

3) How many days sickness has the applicant had over the past two years, and in how many episodes?

4) Are there any current warnings on the applicant's record? If yes, please give details.

5) Is the applicant currently under investigation for any matter (including conduct, capability or performance) under any of your employment policies? If yes, please give details.

6) If relevant, please provide details of the last DBS check completed including date and level. If enhanced and Barred List Check was undertaken, please indicate which Barred List this applied to.

7) Are you aware of any recent/outstanding allegations that were made against the applicant that relate to any safeguarding issues/referrals (including any referrals to the DBS or independent Safeguarding Authority?) If yes, please give details

8) How long have you known the applicant? Please provide dates and in what capacity you have known them.

9) Declaration: The answers given above have been provided in good faith and are correct to the best of my knowledge and belief.

General Comments


Full Name

Direct Contact Number

Job Title

Email Address

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