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National Disability and Mental Health Srevices
M:0487197957
admin@ndmhs.com.au
www.ndmhs.com.au

Reference Request

Thank you for taking the time to complete this reference for .
Please read and check the consent statement, then confirm or update your details entered by .
On the following page you will be asked a series of questions about including your opinion on their work experience and performance.

Step 1 of 2

50%

NDMHS Consent Statement

NDMHS compiles your answer into a reference report for employer and will be saved in his files.
By Checking the consent box below, you agree to the following statements:

I consent to NDMHS using my answers to create a reference report which will be shared with NDIS auditors if needed.
I am aware that the answers given may, under certain circumstances and at the express request of the candidate, be dissolved to the candidate and I believe my answer to be accurate and fair.
I consent to my information being stored in datacenters in Australia for the sole purpose of creating a refrence report.

Consent(Required)

I agree to the privacy policy.(Required)

Your Details

Update any details that are incorrect.

Name

First

Phone

Your Current Job Title

Working Relationship Details

Your professional working relationship with the candidate:

Name of the company (or facility and department) where you worked with the candidate:

Candidate job title / speciality at this time:

When you started working with the candidate:

MM slash DD slash YYYY

When you ended working with the candidate:

Reference Request for

Please answer the following questions compiled by NDMHS

ABILITY TO PERFORM IN THE ROLE

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

	Poor	N/A	1	2	3
Clinical judgement and decision-making skills
Mandatory reporting skills
Ability to follow policies and procedures
Ability to lead, mentor or guide more junior staff members
Ability to manage the behaviour of patients/residents
Ability to administer medications
Observation skills and ability to de-escalate issues if required
Use of electronic based care or medication systems
Ability to manage pressure/busy workload?
Willingness to ask for help if needed

Are there any other comments you would like to add regarding “EMPLOYEE NAME” ability to perform their role?

WORK ETHIC

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

	Poor	N/A	1	2	3
How would you rate “EMPLOYEE NAME”'s punctuality and reliability?
How would you rate “EMPLOYEE NAME”'s organisational skills?
How would you rate “EMPLOYEE NAME”'s initiative?

Are there are other comments you would like to add regarding “EMPLOYEE NAME”'s work ethic, punctuality, and reliability?

COMMUNICATION AND INTERPERSONAL SKILLS

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

Turn your phone sideways to answer the following questions

	Poor	N/A	1	2	3
What is “EMPLOYEE NAME”'s communication with residents and families like?
How would you rate “EMPLOYEE NAME”'s relationship with colleagues?

Do you feel that “EMPLOYEE NAME” was/is respected by their peers?

Yes

Can you provide any additional comments on “EMPLOYEE NAME”'s interpersonal skills?

EMPLOY-ABILITY

Are you aware of any formal complaints, disciplinary or legal actions against “EMPLOYEE NAME”?

Yes

If Yes, please provide details

Would you choose to work with or employ “EMPLOYEE NAME” in the future?

Yes

N/A (still working with applicant)

Hypothetically, if one of your family members needed clinical care, would you be happy for “EMPLOYEE NAME” to provide care to them?

Yes

If No, please provide details

Your Signature

Thank you for completing the reference for “EMPLOYEE NAME”.

As part of our security protocols, we require a digital signature. Please enter your full name into the box below and your signature will be created and applied. By digitally signing below you confirm your identity is “Referee Name” and that you supplied the answers above.

Write Your Name As use Of signature

{E_Name:21}
National Disability and Mental Health Srevices
M:0487197957
admin@ndmhs.com.au
www.ndmhs.com.au

Reference Request

Step 1 of 2

50%

NDMHS Consent Statement

NDMHS compiles your answer into a reference report for employer and will be saved in his files.
By Checking the consent box below, you agree to the following statements:

I consent to NDMHS using my answers to create a reference report which will be shared with NDIS auditors if needed.
I am aware that the answers given may, under certain circumstances and at the express request of the candidate, be dissolved to the candidate and I believe my answer to be accurate and fair.
I consent to my information being stored in datacenters in Australia for the sole purpose of creating a refrence report.

Consent(Required)

I agree to the privacy policy.(Required)

Your Details

Update any details that are incorrect.

Name

First

Phone

Your Current Job Title

Working Relationship Details

Your professional working relationship with the candidate:

Name of the company (or facility and department) where you worked with the candidate:

Candidate job title / speciality at this time:

When you started working with the candidate:

MM slash DD slash YYYY

When you ended working with the candidate:

Reference Request for

Please answer the following questions compiled by NDMHS

ABILITY TO PERFORM IN THE ROLE

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

	Poor	N/A	1	2	3
Clinical judgement and decision-making skills
Mandatory reporting skills
Ability to follow policies and procedures
Ability to lead, mentor or guide more junior staff members
Ability to manage the behaviour of patients/residents
Ability to administer medications
Observation skills and ability to de-escalate issues if required
Use of electronic based care or medication systems
Ability to manage pressure/busy workload?
Willingness to ask for help if needed

Are there any other comments you would like to add regarding “EMPLOYEE NAME” ability to perform their role?

WORK ETHIC

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

	Poor	N/A	1	2	3
How would you rate “EMPLOYEE NAME”'s punctuality and reliability?
How would you rate “EMPLOYEE NAME”'s organisational skills?
How would you rate “EMPLOYEE NAME”'s initiative?

Are there are other comments you would like to add regarding “EMPLOYEE NAME”'s work ethic, punctuality, and reliability?

COMMUNICATION AND INTERPERSONAL SKILLS

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

Turn your phone sideways to answer the following questions

	Poor	N/A	1	2	3
What is “EMPLOYEE NAME”'s communication with residents and families like?
How would you rate “EMPLOYEE NAME”'s relationship with colleagues?

Do you feel that “EMPLOYEE NAME” was/is respected by their peers?

Yes

Can you provide any additional comments on “EMPLOYEE NAME”'s interpersonal skills?

EMPLOY-ABILITY

Are you aware of any formal complaints, disciplinary or legal actions against “EMPLOYEE NAME”?

Yes

If Yes, please provide details

Would you choose to work with or employ “EMPLOYEE NAME” in the future?

Yes

N/A (still working with applicant)

Hypothetically, if one of your family members needed clinical care, would you be happy for “EMPLOYEE NAME” to provide care to them?

Yes

If No, please provide details

Your Signature

Thank you for completing the reference for “EMPLOYEE NAME”.

Write Your Name As use Of signature

Reference Request

Step 1 of 2

50%

NDMHS Consent Statement

NDMHS compiles your answer into a reference report for employer and will be saved in his files.
By Checking the consent box below, you agree to the following statements:

I consent to NDMHS using my answers to create a reference report which will be shared with NDIS auditors if needed.
I am aware that the answers given may, under certain circumstances and at the express request of the candidate, be dissolved to the candidate and I believe my answer to be accurate and fair.
I consent to my information being stored in datacenters in Australia for the sole purpose of creating a refrence report.

Consent(Required)

I agree to the privacy policy.(Required)

Your Details

Update any details that are incorrect.

Name

First

Phone

Your Current Job Title

Working Relationship Details

Your professional working relationship with the candidate:

Name of the company (or facility and department) where you worked with the candidate:

Candidate job title / speciality at this time:

When you started working with the candidate:

MM slash DD slash YYYY

When you ended working with the candidate:

Reference Request for

Please answer the following questions compiled by NDMHS

ABILITY TO PERFORM IN THE ROLE

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

	Poor	N/A	1	2	3
Clinical judgement and decision-making skills
Mandatory reporting skills
Ability to follow policies and procedures
Ability to lead, mentor or guide more junior staff members
Ability to manage the behaviour of patients/residents
Ability to administer medications
Observation skills and ability to de-escalate issues if required
Use of electronic based care or medication systems
Ability to manage pressure/busy workload?
Willingness to ask for help if needed

Are there any other comments you would like to add regarding “EMPLOYEE NAME” ability to perform their role?

WORK ETHIC

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

	Poor	N/A	1	2	3
How would you rate “EMPLOYEE NAME”'s punctuality and reliability?
How would you rate “EMPLOYEE NAME”'s organisational skills?
How would you rate “EMPLOYEE NAME”'s initiative?

Are there are other comments you would like to add regarding “EMPLOYEE NAME”'s work ethic, punctuality, and reliability?

COMMUNICATION AND INTERPERSONAL SKILLS

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

Turn your phone sideways to answer the following questions

	Poor	N/A	1	2	3
What is “EMPLOYEE NAME”'s communication with residents and families like?
How would you rate “EMPLOYEE NAME”'s relationship with colleagues?

Do you feel that “EMPLOYEE NAME” was/is respected by their peers?

Yes

Can you provide any additional comments on “EMPLOYEE NAME”'s interpersonal skills?

EMPLOY-ABILITY

Are you aware of any formal complaints, disciplinary or legal actions against “EMPLOYEE NAME”?

Yes

If Yes, please provide details

Would you choose to work with or employ “EMPLOYEE NAME” in the future?

Yes

N/A (still working with applicant)

Hypothetically, if one of your family members needed clinical care, would you be happy for “EMPLOYEE NAME” to provide care to them?

Yes

If No, please provide details

Your Signature

Thank you for completing the reference for “EMPLOYEE NAME”.

Write Your Name As use Of signature

Reference Request

NDMHS Consent Statement

Your Details

Working Relationship Details

Reference Request for

Please answer the following questions compiled by NDMHS

ABILITY TO PERFORM IN THE ROLE

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

WORK ETHIC

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

COMMUNICATION AND INTERPERSONAL SKILLS

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

Turn your phone sideways to answer the following questions

EMPLOY-ABILITY

Your Signature

Reference Request

NDMHS Consent Statement

Your Details

Working Relationship Details

Reference Request for

Please answer the following questions compiled by NDMHS

ABILITY TO PERFORM IN THE ROLE

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

WORK ETHIC

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

COMMUNICATION AND INTERPERSONAL SKILLS

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

Turn your phone sideways to answer the following questions

EMPLOY-ABILITY

Your Signature

Reference Request

NDMHS Consent Statement

Your Details

Working Relationship Details

Reference Request for

Please answer the following questions compiled by NDMHS

ABILITY TO PERFORM IN THE ROLE

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

WORK ETHIC

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

COMMUNICATION AND INTERPERSONAL SKILLS

Can you please rate “EMPLOYEE NAME” from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

Turn your phone sideways to answer the following questions

EMPLOY-ABILITY

Your Signature

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