APPENDIX 5

VERBAL REFERENCE REPORT

It is Hauora Tairāwhiti policy to ensure that all potential appointments undergo a thorough reference check prior to
being offered a job. A minimum of two verbal reference checks will be undertaken, and one must be conducted
with the applicant’s most current direct report/Manager or Clinical Leader. References will be obtained only from
persons whom the applicant has authorised Hauora Tairāwhiti to contact by consenting this on the declaration
section of the application form. Reference checks are relied upon to validate appointments so should be completed
in full and be as legible as possible.
Name of Applicant / Date
Date:
Position Applied For

Name of Referee / Contact Details

Contact Details:
Referees Position / Relationship to
the Applicant
Reference Recorded By/ Date
Date:

1. How long have you known the Applicant?

Number of years / months:

______________________________________________________________________

Dates worked with applicants:

___________________________________________________________________

2. What position(s) did the applicant hold and what were their key responsibilities? (how well do they accept
responsibility, supervisory functions)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

___________________________________________________________________________________________

3. For what period did they hold the position(s)?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

4. Can you please confirm their reason for leaving?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

5. Did the applicant have any leadership responsibility? (technical leadership, develops high performance,
goal oriented, visionary)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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6. How do they perform in an autonomous role? (maintains focus, delivers on objectives, asks for help)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

7. Please describe their ability to communicate effectively, both oral and written (share information,
communicate openly, directed at the appropriate people, presenting to groups, English if not their first language)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

8. Can you please describe their level of participation within the team?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

9. Can you please describe their level of interaction with other teams (if applicable)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

10. Maintaining professional relationships is essential in our environment, how did the applicant develop
these at your company? (managers, fellow staff, patients / customers, contribution to the team)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

11. How would you describe their overall work performance?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

12. Have you dealt with the applicant over any issue that has affected their work? (ie. drugs, alcohol, prolonged
periods off work due to accident/illness or psychological problems)
_____________________________________________________________________________________________

_____________________________________________________________________________________________

13. a) Has the applicant been subject to any disciplinary action or legal proceedings?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

b) Is there any reason, including past events, as to why this person may pose any risk whatsoever to
vulnerable persons including children and elderly?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

14. Are you aware of any convictions that may impact on this person’s ability to do the role or place patients
at risk, particularly those considered vulnerable i.e. children and elderly?

_____________________________________________________________________________________________
_

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_____________________________________________________________________________________________
_

15. Can you please describe the applicants’ strengths, skills or any special achievements whilst at your
facility? Do you think they have the skills for this job?

_____________________________________________________________________________________________

_____________________________________________________________________________________________
_

16. Are there any areas that you felt needed further developing and up-skilling?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

17. This organisation has a commitment to cultural safety, health and safety and quality improvement. Are
you aware of any issues they might have with these?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

18. Can you describe how the applicant has upheld and demonstrated the values and behavioural
expectations within your workplace?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Can you assess the following (provide examples if applicable): Poor Good Very Excellent
Good
Adaptable
Accountability (Takes responsibility for their results)
Goes beyond expectations
Team player (good contributor within a team)
Customer Focus (Puts the patient first)
Incorporates safe practises

Meets deadlines (motivated, energised)

Practices innovation (seeks improvements)

Works under pressure (how they handle stress or a busy

workload)

Follows instructions (and asks for help)

Willingness to learn (accepts responsibility for self learning)

Punctuality / Time Management (prioritises)

Attendance Record

17. Do you have any further comments you would like to tell us about the applicant? Is there anything
relevant you would like to add for us to be aware of?

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_____________________________________________________________________________________________

_____________________________________________________________________________________________

19. Would you re-employ them? YES/NO

20. The final question relates to the Privacy Act principles

May we make your comments available, confidentially, to the applicant if requested? YES/NO

ADDITIONAL QUESTIONS FOR CLINICAL STAFF

1. How would you rate their overall clinical skills, clinical judgment and theoretical knowledge?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

2. Are they able to modify their practice to meet the needs of people from a different cultural background?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

3. How would you feel about the applicant treating your family?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

4. Has any competency or health issues ever been raised with the applicant?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

5. Other questions you may want to ask;

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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