Reference Request Form

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.

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.

I agree to the privacy policy.

Your Details

Update any details that are incorrect.

Your name

Your email

Your Phone No

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:

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 from 1 to 5 on the following attributes: (1 being Poor to 5 being Excellent)

Turn your phone sideways to answer the following questions

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

WORK ETHIC

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

Turn your phone sideways to answer the following questions

Are there any other comments you would like to add regarding work ethic, punctuality, and reliability?

COMMUNICATION AND INTERPERSONAL SKILLS

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

Turn your phone sideways to answer the following questions

Do you feel that was/is respected by their peers?
YesNo
Can you provide any additional comments on interpersonal skills?

EMPLOY-ABILITY

Are you aware of any formal complaints, disciplinary or legal actions against ?
YesNo
Would you choose to work with or employ in the future?
YesNoN/A (still working with applicant)
Hypothetically, if one of your family members needed clinical care, would you be happy for to provide care to them?
YesNo

Your Signature

Thank you for completing the reference for .

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 and that you supplied the answers above.

Write Your Name As use Of signature