CIPD Academic Membership
Referee Assessment form
CANDIDATE DETAILS:
Title:
First name:
Last name:
The candidate above has applied for CIPD Academic Membership. You have been selected as a Colleague
who has worked with them professionally and/or is familiar with their work. You are asked to provide
feedback in relation to 8 behaviours, which are presented in 3 clusters. This information will be used along
with other evidence to ascertain the candidate’s suitability for Academic Membership of the CIPD. If you
come across a specific section where you do not have sufficient evidence or are not best placed to
comment please feel free to leave this blank. Please type your answers in the boxes provided. As a guide,
your answers for each question should be approximately 150 words. Don’t worry if your examples are just
under or over this, but anything too short or long is unlikely to be suitable.
REFEREE: ABOUT YOU
Title:
First name:
Are you a CIPD member?
Last name:
Yes
Job title:
No
If yes, please indicate
membership number
Organisation:
Please provide a daytime telephone number. We may need to contact you to clarify the statements made or
to obtain additional information about the comments or examples.
Daytime contact number:
Email:
Your professional relationship with the candidate: Please indicate whether you are a:
Client
Line manager
Senior work colleague or professional expert
Other (Please specify)
How long have you known the candidate (in years)?
Which of the following areas would you say form the main focus of the candidate’s role? Maximum of two.
Academic teaching or lecturing
Research design and delivery
Academic or professional programme design
Administration/management only
Other (please specify)
I certify that to the best of my knowledge, the information that I have provided above is a true and honest
reflection of the candidate.
Name (block capitals):
Date:
Signature
Data Protection: For your security and peace of mind, any information you submit to CIPD will be processed in accordance with the
provisions of the Data Protection Act 1998.
Behavioural Clusters:
Chartered Institute of Personnel and Development
Insights and Influence
B1 Curious
Shows an active interest in the internal and external environment and in the continuous development and
improvement of self and others at both organisation and individual levels. Is open minded with a bias and
willingness to learn and enquire. Questions current thinking and knowledge, investigates and seeks
insights.
B2 Decisive Thinker
Demonstrates the ability to analyse and understand data and information quickly. Is able to use information,
insights and knowledge in a structured way, using judgment wisely to identify options and make robust and
defendable decisions.
B3 Skilled Influencer
Demonstrates the ability to influence across a complex environment, to gain the necessary commitment,
consensus and support from a wide range of diverse stakeholders in pursuit of organisation benefit.
Question 1: Please give an example and provide comments of when you have known the candidate
to demonstrate Insights and Influence
Operational Excellence:
B4 Driven to deliver
Demonstrates a consistent and strong bias to action, taking accountability for delivery of results both
personally and/or with others. Actively plans, prioritises and monitors performance, holding others
accountable for delivery.
B5 Collaborative
Works effectively and inclusively with colleagues, clients, stakeholders, customers, teams and individuals
both within and outside of the organisation/institute. Listens to and shows consideration for other people’s
views, beliefs and judgment. Is tactful, understands and respects individual differences. Able to handle
sensitive and controversial situations effectively.
B6 Personally credible
Builds a track record of reliable and valued delivery using relevant technical expertise and experience and
does so with integrity and in an objective manner. Consistently delivers on commitments and promises. Is
dependable and can be trusted by colleagues to be impartial and discrete. Able to hold difficult
conversations or surface the truth when needed.
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Chartered Institute of Personnel and Development
Question 2:
Please give an example with comments of when you have known the candidate to demonstrate
Operational Excellence
Stewardship:
B7 Courage to challenge
Shows courage and confidence to speak up and challenge others even when confronted with resistance or
unfamiliar circumstances. Champions the adoption of ethical and professional standards within the
department.
B8 Role Model
Consistently leads by example. Understands the institution’s values and expected behaviours and helps to
ensure an adherence to institutional and professional values amongst team members or colleagues.
Question 3:
Please give an example with comments of when you have known the candidate to demonstrate
Stewardship
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Chartered Institute of Personnel and Development
Question 4:
 Please use your experience of the candidate to give some developmental feedback for their
consideration for their ongoing continuing professional development.

Which of the behaviours would you rate as the candidate’s strongest and which would you
regard as behaviours that the candidate could develop further.
When you have completed the form, you can scan your documents and email to: academicmembership@cipd.co.uk
Or post to:
Academic Membership
Assessment Team
CIPD
151 The Broadway
London
SW19 1JQ
If you have any questions please call us on +44 (0)20 8612 6623. If you wish to read more information about CIPD
Academic Membership, you may do so via the following link: cipd.co.uk/centres/academic-membership/default
Thank you for taking the time to complete this form.
Chartered Institute of Personnel and Development
151 The Broadway London SW19 1JQ UK
Tel: +44 (0)20 8612 6200 Fax: +44 (0)20 8612 6201
Email: cipd@cipd.co.uk Website: cipd.co.uk
Issued: March 2016 Reference: © Chartered Institute of Personnel and Development 2016
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