Reference Request Form

Employment Details:

Employee Name* Employee Position Undertaken* Employer* Relationship to Employee*

Dates of Employment:

From:* To:* Would you re-employ?* If no, please provide details Please confirm reason for leaving positon*

Have you observed this applicant working with children?* During the period the applicant worked in your organisation, did you or do you now have any concerns about their behaviour or conduct when working with a child or children?* Were there instances where you had concerns that the applicant did not always behave with integrity in their employment, such as not dealing with others in an ethical manner, not declaring or managing a conflict of interest appropriately or not dealing with sensitive or confidential information in an appropriate way?* To the best of your knowledge has this applicant been the subject of disciplinary action or suspended from teaching in relation to inappropriate or unprofessional conduct toward a child?* Ability to manage challenging children behaviour:* Organisation:* Rapport with Staff:* Rapport with Students:* Initiative:* Punctuality:* Reliability:* Communication skills: Suitability to work with children:* Describe the main responsibilities of the applicant whilst employed at your school / organisation:*

Reference completed by:

Name:* Current Position:* School Name /Company:* Signed:* Date:*

Thank you for your time and co-operation in completing this form, all information will be treated confidentially.