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Do you need to send a reference to us?

This reference should include factual, evidence based information and
there should be nothing contained in this reference that has not already
been discussed with the agency worker.
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Worker Details

Worker Name
Worker Job title
Reason for Leaving
Employed from (MM/YYYY)
Did the worker complete the assignment?
If no, please explain
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Competency Assessment

Please assess the worker’s competency in the following areas:

SECTION A

Reliability
Verbal communication
Written communication
Report writing
IT skills
Punctuality

SECTION B

Ability to deal with situations appropriately with
regards to confidentiality
Ability to distinguish between confidentiality and
when disclosure is required
Ability to set and maintain appropriate
professional boundaries with colleagues
Ability to set and maintain appropriate boundaries
with service users
Ability to adhere to professional codes of conduct/
practice

SECTION C

Ability to work effectively as part of a Social Work team
Ability to work effectively in a multidisciplinary environment with other professionals and organisations
Ability to work under pressure, and to maintain judgement
Ability to effectively and appropriately manage risk
Ability to work with children, young people, or vulnerable people
Ability to report and take appropriate action, in cases of suspected abuse

SECTION D

Knowledge of legislation relevant to their area of work
Ability to manage effectively a large caseload
Conduct/performance in relation to safety & welfare of children, young people, or vulnerable adults
Duty experience
Flexibility to support the needs of the organisation
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General Assessment

Please summarise the worker’s key duties &
responsibilities
Please outline briefly any areas where the worker has
demonstrated particular strengths
Please detail any areas where the worker would
benefit from development
Would you re-employ this worker in a similar role?
If you would not re-employ, please can you explain why?
Has the worker been subject to any allegations/
investigations?
If yes, please explain
Are you aware of any referrals to/or pending investigations by HCPC with regards to the workers fitness to practice?
If yes, please explain
Has the worker been the subject of any child protection concerns?
If yes, please explain
Is the worker subject to any current disciplinary
investigation or live disciplinary sanction?
If yes, please provide further detail
Any other comments
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Declaration

I confirm that I am authorised to give the reference
details outlined on this form.

By supplying this reference I understand I am giving
you permission to disclose information contained in
this document to third parties - to include the
candidate and clients.

Your Full Name
Organization
Job title
In what capacity do you know the worker
Contact Telephone Number
Work Email
Draw Signature with mouse or touch

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Temp / Contract Positions
Permanent Employment

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