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Unbound Medical References

Referee first name

Referee last name

Candidate's date started at your organisation

Candidate's date ended at your organisation

Organisation Name

Job Title

Reason for leaving

Relationship to referee

Any concerns with the candidate's performance or conduct?

If ‘yes’, please provide brief details including:

• any disciplinary, performance management or legal action (past or present), while in your employment;

• any Resident / Patient complaints made against them, including unresolved complaints

• any issues with any professional / regulatory body including referrals to the DBS or CQC; and / or

• any concerns about the candidate’s fitness to practice in the context of public and / or patient / resident safety

State whether you are completely satisfied that the candidate is suitable to work with adults at risk and children and, if not, specific details of your concerns and the reasons why you believe that the candidate may be unsuitable.

Any other information you consider relevant or appropriate?

Signature

Signature