Conﬁ dential Clinical Reference Form
Ontario Universities’ Application Centre
For Speech-Language Pathology and/or Audiology Applicants Only
170 Research Lane
Guelph ON N1G 5E2 Canada
Area Code & Phone Number
Area Code & Phone Number
To the Referee
Applicants to programs in Speech-Language Pathology and/or Audiology
6. If you have any questions, please contact the universities directly:
must have completed a total minimum of 14 hours of work or volunteer
service in a communication disorders setting under the supervision of a
Western University – School of Communication Sciences and Disorders:
qualiﬁ ed speech-language pathologist or audiologist.
Check each item at the point on the scale that best indicates your rating
of the individual working under your supervision as compared to other
volunteers or employees. Please type or print legibly in black ink.
Do not email this form to ORPAS, as it is not a secure method of
On your offi cial stationery, please comment on interpersonal skills and
other characteristics that may provide some information on this individual’s
Use regular postal services. Due to the volume of mail ORPAS receives, the
suitability for the profession of speech-language pathology and/or
use of courier services physically strains the staff responsible for opening
and processing any mail sent via courier. Please allow enough time to post
your Conﬁ dential Clinical Reference Form by regular mail.
4. Forward this assessment directly to ORPAS. Complete this form in
conﬁ dence and do not make it available to the applicant. The applicant will
Keep a copy of this reference for your ﬁ les.
not have access to this completed form once you submit it to ORPAS.
Return this assessment and accompanying letter by January 8, 2016.
ORPAS will acknowledge receipt of this form.
(ability to act or to speak without off ending or upsetting others)
Interacts appropriately with supervisor and other professionals
Interacts appropriately with clients and family members
Demonstrates keen interest in profession
Demonstrates professionalism (manner, ownership, reliability)
Communicates eff ectively – speaking
Communicates eff ectively - writing
Demonstrates emotional maturity
Asks relevant questions
Arrives at scheduled times
Recognizes own limitations
Demonstrates respect for social and cultural diff erences
Completes tasks (thorough and timely)
Unable to Rate Suitability
Overall Suitability to the Profession
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