Health Information and Quality Authority
Social Services Inspectorate
Reference Form for persons involved in the management of a designated centre
(to be completed by persons providing references)

The Health Information and Quality Authority's Social Services Inspectorate, referred to in the Health Act 2007 as the Office of the Chief Inspector, is responsible for the registration and inspection of designated centres. An important part of protecting vulnerable people involves ensuring that only fit people are involved in owning, managing and working in residential care.

The person named below is involved in the managementof a designated centre under the Health Act 200.This person has nominated you as someone who can comment as to his/her suitability to be involved in the management of a designated centre. We would appreciate if you would complete this reference form in relation him/her.

Person details

Name of person:
Address:
Telephone number:
Name of designated centre:
Email address:
Address of designated centre:

Referee details

Name of referee:
Occupation:
Address:
Telephone number/s:
Email address:
How long have you known the person?
In what capacity do you know the person?

Participating in the management of a designated centre involves access to vulnerable people. Based on your knowledge of the person have you any reason at all to be concerned about him/her having access tovulnerable people?

Yes No

If you have answeredYeswe will contact you to discuss further.

Attributes

Please state your belief as to whether the person has the following important personal attributes:

Attribute / Yes / No
Will this person exercise personal responsibility for the centre?
Is this person honest?
Is this a person of integrity?
Does this person have a caring attitude?
Is this person a good organiser and manager?
Can this person promote quality?
Any other comments you wish to make that would help theAuthority in assessing this person:

Please be advised that this reference may be requested by the person under the Freedom of Information Acts, 1997 and 2003. Should this occur, you will be contacted prior to any decision to disclose or release.

Declaration

Thank you for completing this form. Please read and sign the declaration below.

Section 47 and Section 79(1)(b) of the Health Act 2007 make it an offence for a person to make a statement which is false or misleading in, or in respect of, an application for registration or renewal of registration.

I certify that the information provided is, to the best of my knowledge and belief, accurate and complete in every respect.

Signed: ______

Name: (Please Print)

Date:

On completion of this form

Please return to:

Registration Office

The Health Information and Quality Authority

Social Services Inspectorate

Unit 1301

City Gate

Mahon

Cork

Tel. (021)240 9340

Email address:

RF09