AIREDALE NHS FOUNDATION TRUST

REFERENCE QUESTIONNAIRE
Applicants Name:
Numele aplicantului
Referees Name:
Numele celui ce ofera
refereferinta:
Referees Job Title:
Pozitia celui ce ofera
referinta:
Name of Organisation
Numele Organizatiei
Date applicant started in post
Data la care a inceput colaborarea
Date applicant left post
Data la care s-a incheiat colaborarea
How long have you known the applicant?
De cat timp cunoasteti aplicantul?
When was your last professional contact with the nurse?
Canda ti avut ultimul contact professional cu aplicantul?
In which professional capacity have you known this nurse?
In ce capacitate (dpdv profesional) asti cunoscut aplicantul?
Can you comment on the nature of the practice and patient population (e.g. gender, age, range of presentations)
encountered in the applicants professional practice?
Puteti da mai multe detalii despre natura muncii si a tipurilor de pacienti cu care acesta a avut de a face in timpul
serviciului/practicii?

CLINICAL SKILLS AND KNOWLEDGE BASE

Excellent
Execelent

Good
Bun

Adequate
Adecvat

Poor
Slab

Not
observed
Neobservat

Clinical Judgement and Decision-Making

Luarea deciziei si diagnosticarea

Excellent

Good

Adequate

Poor

Not
observed

Medical Record-Keeping
Evidenta Medicala

Excellent

Good

Adequat
e

Poor

Not
observed

Procedural Skills (bearing in mind the applicants level of

experience)
Abilitati procedurale

Excellent

Good

Adequat
e

Poor

Not
observed

History-Taking, Physical Examination & Presentation of Findings

Istoricul pacientilor, examenele fizice si prezentarea pacientului

Comments:
Comentarii:

2
WORK ETHICS / RELIABILITY / PUNCTUALITY
Punctuality and Reliability (Satisfactory Completion of Set Tasks On
Time)
Punctualitate si increderea

Excellent

Good

Adequate

Poor

Not observed

Organisational Skills
Abilitatile organizatorice

Excellen
t

Good

Adequat
e

Poor

Not
observed

Initiative
Initiativa

Excellen
t

Good

Adequat
e

Poor

Not
observed

Communication/Rapport with Patients and Families

Comunicarea in raport cu pacientii si familiile acestora

Excellen
t

Good

Adequat
e

Poor

Not
observed

Relationships with Other Health Professionals

Relatii cu alte cadre medicale

Excellen
t

Good

Adequat
e

Poor

Not
observed

Comments:
Comentarii:

COMMUNICATION AND INTERPERSONAL SKILLS

Comments:
Comentarii:

EMPLOYABILITY
Are you aware of any medical condition, mental or physical (including substance abuse or
dependence) which might adversely affect this nurses ability to competently and safely practise
medicine?
Cunoasteti orice conditie medicala, mental sau fizica (a aplicantului)ce ar putea afecta abilitatea si
practicarea in siguranta a meseriei de asistent medical?

Yes/Da

No/Nu

Yes/Da

No/Nu

Yes/Da

No/Nu

Yes/Da

No/Nu

Comments:
Comentarii:

Are you aware of any formal complaints, disciplinary or legal action against this nurse?
Aveti cunostinta de anumite plangeri disciplinare sau legale facute la adesa aplicantului?
Comments:
Comentarii:

Would you offer this nurse another post in your unit?

Ati oferi aplicantului un alt post in organizatia dvs.?
Would you entrust the care of a member of your family to a nurse of this calibre?
Ati avea incredere ca un membru al familiei dvs. Sa fie in grijit de un angajat de calibrul accestul
applicant?
Comments:
Comentarii:

Signature:
Semnatura

Date:
Data:

Stamp:
Stampila:
DATA PROTECTION ACT 1998 References will not be disclosed without your permission.
I do/do not* give my permission to this reference being disclosed to the applicant/employee.
* Please delete.