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Reference Request Form

The document is a reference request from Chrysalis Homecare for Jake Cinco, who has applied to register with them. It requests a reference from Mr. Nino Archie Labordo, who was Jake Cinco's clinical instructor at nursing college. The reference form details Jake Cinco's dates of employment, position held, reason for leaving, ratings of his abilities, any criminal convictions, positive aspects of his work, main duties of the post, and a declaration signed by Mr. Labordo.

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albus198
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101 views

Reference Request Form

The document is a reference request from Chrysalis Homecare for Jake Cinco, who has applied to register with them. It requests a reference from Mr. Nino Archie Labordo, who was Jake Cinco's clinical instructor at nursing college. The reference form details Jake Cinco's dates of employment, position held, reason for leaving, ratings of his abilities, any criminal convictions, positive aspects of his work, main duties of the post, and a declaration signed by Mr. Labordo.

Uploaded by

albus198
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Private and confidential

20/08/2010

Mr Nino Archie Labordo


Clinical Instructor
Remedios T Romualdez Medical Foundation College
Calanipawan
Phillipines

RE: Jake Cinco

The above named person has applied to register with Chrysalis Homecare. Chrysalis
Homecare is registered with the Care Quality Commission for the provision of domiciliary
care services.

As part of our stringent recruitment and vetting process all applicants must have recent,
relevant and professional references before they are able to work. The references must
be completed by the applicant’s manager within the organisation and must be signed
and dated by the referee. The references must be completed and returned on either your
organisation’s headed paper or stamped with your organisation’s stamp.

We would appreciate it if you would complete the enclosed reference form as


soon as possible, following the guidelines as detailed above. Please return
either in the free post envelope provided, or fax it back on 0208 686 8201

With reference to the Rehabilitation of Offenders Act 1974:

“In order to protect the public, the post to which application is being made is exempt
from section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the
Rehabilitation of Offenders Act 1974 (Exemptions) order 1975. It is not, therefore, in
any way contrary to the Act to reveal any information you may have concerning
convictions which would otherwise be considered as “spent”, in relation to this applicant,
and which you consider relevant to the applicant’s suitability for employment. Any such
information will be kept in strictest confidence, and used only in consideration of this
applicant for a position where such an exemption is appropriate”.

Please do not hesitate to contact me 0208 688 5825 if there is anything you would like
to discuss. Thank you for your time and attention, we look forward to receiving your
reference.

Yours sincerely

Barbara Parris
Recruiter

V1AUG09
Reference request form

Reference requested
This section is to be completed by the Chrysalis Please affix the official stamp here. This reference will
Homecare employee prior to sending out. not be considered valid unless accompanied by an
Reference requested from: official stamp or stationery e.g. a compliments slip.

Name: Mr Nino Archie Labordo

Remedios T Romualdez Medical


Foundation College

Postcode:

Applicant details
Title: Forename: JAKE Surname: CINCO

Dates of employment
from: to:

Position held:

How do you know this person? My student in the College of Nursing

Reason for leaving: Graduated the BSN degree

Would you re-employ this candidate (subject to equal opportunities)? Yes x No 

If no, please state your reason

How would you rate the applicant’s ability?


Cause for Don’t
Excellent Good Adequate Poor
concern know
Reliability X

Communication skills X
Patience/listening X
skills
Honesty and integrity X

Ability to use initiative X


Ability to carry out X
tasks
Knowledge of care X
practice
Presentation X

V1AUG09
Are you aware of the applicant
YES! Mr. Cinco was been my student.
having any criminal convictions?
NONE

Please highlight any positive Easy to deal with


aspects of the applicant’s work.
Committed and hardworking
Good personality

Were there any concerns about None


any aspects of the applicant’s
work?

Please detail the main duties of the post and attach a job description if possible.

Student Description at Clinical Setting;


 Audits, assesses and submits reports of the patient (Nursing
Care Plan, Pharmacology Sheets, Laboratory Reports, Patient
Comprehensive History)
 Go on duty 15 minutes before the shift. In complete uniform
and paraphernalia’s.
 Attends the endorsement and nursing rounds.
 Take assigned patient. Assess, plan, implement and evaluate
nursing care rendered.
 Reports and updates nursing staff and health care team
including the attending physician regarding patient condition.
 Carries out doctors order properly ( Medication administration,
referrals and collaboration, therapeutics and management)
 Reports care rendered to clinical instructor.
 Attends pre and post conference, bedside clinics and ward
evaluation.

V1AUG09
How many sick days did the applicant have in the last 12 months?

Are you aware of any periods of long term sickness? Yes No x
If yes, please detail:

Declaration
Print name: NINO ARCHIE S. LABORDO, RN, MSc Signature:

Position: Clinical Instructor –RTRMF College of Date: 8-27-2010


Nursing, Tacloban City

V1AUG09

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