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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
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Locums
Temp / Contract Positions
Permanent Employment

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