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Ref­er­ence Check Form

Infor­ma­tion col­lect­ed on this form is used sole­ly for the pur­pose of assess­ing the applicant’s suit­abil­i­ty for employ­ment with ProMED Tas­ma­nia. It is han­dled in accor­dance with the Pri­va­cy Act 1988 (Cth) and ProMED Tasmania’s Pri­va­cy Pol­i­cy (PMT-POL-003). This form is con­fi­den­tial and will not be shared with the applicant.

Applicant & Referee Details

Referee Relationship to Applicant 

Applicants Employment Information

What was the applicants role/capacity in your organisation?

When was the applicant employed in your organisation?

Why did the applicant leave your organisation? (if known)

Performance Assessment

Please rate the applicant in the following areas:

Safeguarding & Professional Conduct

To the best of your knowledge:
Did the applicant demonstrate appropriate professional boundaries with patients, clients, or members of the public? 
Were there ever any concerns regarding the applicant’s professional conduct, patient safety, or behaviour? 

Suitibility for Role

Would you re-employ this person if given the opportunity? 
How suitable do you believe the applicant is for work within event medical, first aid or patient care environments? 

Please provide any further observations

Additional Comments

Referee Declaration

I confirm that the information provided above is accurate to the best of my knowledge, and I consent to ProMED Tasmania using this information for the purpose of assessing the applicant’s suitability for employment.
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Date