Airedale Reference Form
4
AIREDALE NHS FOUNDATION TRUST REFERENCE QUESTIONNAIRE Applicant’s Name: Numele aplicantului Referee’s Name: Numele celui ce ofera Referee’s Job Title: Pozitia celui ce Name of Organisation Numele Organizatiei Date applicant started in post Date applicant left post Data la care s-a incheiat 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 Can you comment on the nature of the practice and patient population (e.g. gender, age, range of presentations) encountered in the applicant’s 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 History-Taking, Physical Examination & Presentation of Findings Istoricul pacientilor, examenele fizice si Excellent Execelent Good Bun Adequat e Adecvat Poor Slab Not observed Neobserva Clinical Judgement and Decision-Making Luarea deciziei si diagnosticarea Excellent Good Adequat e Poor Not observed Medical Record-Keeping Evidenta Medicala Excellent Good Adequa te Poor Not observed Procedural Skills (bearing in mind the applicant’s level of experience) Abilitati procedurale Excellent Good Adequa te Poor Not observed
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Transcript of Airedale Reference Form
AIREDALE NHS FOUNDATION TRUSTREFERENCE QUESTIONNAIRE
Applicant’s Name: Numele aplicantului
Referee’s Name:Numele celui ce ofera refereferinta: Referee’s Job Title: Pozitia celui ce ofera referinta: Name of OrganisationNumele OrganizatieiDate applicant started in postData la care a inceput colaborarea
Date applicant left postData 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 applicant’s 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
History-Taking, Physical Examination & Presentation of FindingsIstoricul pacientilor, examenele fizice si prezentarea pacientului
ExcellentExecelent
GoodBun
AdequateAdecvat
PoorSlab
Not observed
Neobservat
Clinical Judgement and Decision-MakingLuarea deciziei si diagnosticarea
Excellent Good Adequate PoorNot
observed
Medical Record-KeepingEvidenta Medicala
Excellent GoodAdequat
ePoor
Not observed
Procedural Skills (bearing in mind the applicant’s level of experience)Abilitati procedurale
Excellent GoodAdequat
ePoor
Not observed
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 SkillsAbilitatile organizatorice
Excellent
GoodAdequat
ePoor
Not observed
InitiativeInitiativa
Excellent
GoodAdequat
ePoor
Not observed
Comments:Comentarii:
COMMUNICATION AND INTERPERSONAL SKILLS
Communication/Rapport with Patients and FamiliesComunicarea in raport cu pacientii si familiile acestora
Excellent
GoodAdequat
ePoor
Not observed
Relationships with Other Health ProfessionalsRelatii cu alte cadre medicale
Excellent
GoodAdequat
ePoor
Not observed
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
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?
Yes/Da No/Nu
Comments:Comentarii:
Would you offer this nurse another post in your unit?Ati oferi aplicantului un alt post in organizatia dvs.?
Yes/Da No/Nu
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?
Yes/Da No/Nu
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.
