Employer Reference FormPlease complete all relevant and appropriate fields before submitting. Name of applicant * First Name Last Name Date of birth * MM DD YYYY Date of employment start * MM DD YYYY Date of employment end * MM DD YYYY Applicant's Job Title * Please confirm the applicant's current/most recent job title and grade if applicable Please confirm the applicant's reason for leaving (if known) * Please detail how many sick days the individual has had over the last 2 years * (Number of days / Number of episodes) Are there any current warnings on the applicant's record? * Please select the relevant option Yes No Is the applicant currently under investigation for any matter under any of your employment policies? * Please select the relevant option Yes No Are you aware of any allegations that were made against the applicant that relate to any safeguarding issues/referrals (including any referrals to DBS/professional or regulatory bodies)? * Please select the relevant option Yes No Referee name (please print) * First Name Last Name Referee job title * Name of organisation * Contact details * Email Phone * (###) ### #### Signature Date MM DD YYYY Failure to share information with other registered persons, regulatory bodies and law enforcement agencies where to do so would assist in safeguarding care recievers from harm will be an offence which if prosecuted and convicted, the registered person would be liable to a fine of up to £50,000. Data Protection (Jersey) Law 2018 This reference request is subject to the provisions of the Data Protection (Jersey) Law 2018. It is the policy of Autism Jersey to disclose their content if an appropriate request is received from the individual. As provided for in the Law, the identity of the person signing and completing the reference form will be withheld in the event of a disclosure request. The reference for a successful candidate will be held on their personal file and information relating to unsuccessful candidates will be retained for a limited period of time, in accordance with Autism Jersey's policies on the retention of records. Employees have a right to see their personal file and therefore will have an opportunity to see this reference. The answers given above have been provided in good faith and are correct to the best of my knowledge and belief * Yes Thank you!
