Your details have been passed to us by a worker who requires a reference. Please fill in the simple form below and sign or initial, before clicking submit. Thanks in advance for your help. About the candidateCandidate's name* First Last Job title / band Place of work* Ward / department Date of employment from* Day Month Year Date of employment to* Day Month Year Reason for leaving if known / applicableDid you work in a supervisory position to the candidate named? Please select yes or no.* Yes No Candidate ratingPlease rate the candidate for the following attributes:*Very poorPoorAverageGoodVery goodReliabilityProfessional attitude / standardsClinical skills / abilitiesPatient handlingAbility to work as part of a teamDoes the candidate have any recent or ongoing disciplinary action or referrals?* Yes No If yes, please provide details:*Please use this area below to include any additional comments about the candidate.About youThe person providing the referenceYour name* First Last Your position and equivalent band level* Please provide your professional email address* Sign and submitPlease sign or initial to confirm that the information you're submitting to Bluestones Medical is accurate.*When you digitally sign and submit this form, a PDF copy will be sent to Bluestones Medical.CommentsThis field is for validation purposes and should be left unchanged.