Confidential Clinical Reference Form
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1
2Confi dential Clinical Reference Form
Return to
ORPAS
Ontario Universities’ Application Centre
For Speech-Language Pathology and/or Audiology Applicants Only
170 Research Lane
Guelph ON N1G 5E2 Canada
Referee
Applicant
Referee’s Name
Position
Applicant’s Name
Department
Area Code & Phone Number
Address
Email Address
Postal Code
Area Code & Phone Number
Email Address
To the Referee
1.
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
University
of
Toronto
–
Speech-Language
Pathology:
416-978-1794;
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.
519-661-3227
2.
Check each item at the point on the scale that best indicates your rating
Notes:
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
communication.
3.
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
audiology.
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.
5.
Return this assessment and accompanying letter by January 8, 2016.
ORPAS will acknowledge receipt of this form.
Characteristics
Ratings
Top 2%
Top 10%
Next 20%
Next 20%
Lower 50%
Unable
Comments
Appropriate Rating
Outstanding
Excellent
Above
Average
Below
to Evaluate
Average
Average
Demonstrates tact
(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
Demonstrates preparedness
Demonstrates initiative
Asks relevant questions
Arrives at scheduled times
Recognizes own limitations
Demonstrates respect for social and cultural diff erences
Completes tasks (thorough and timely)
Extremely
Very
Somewhat
Somewhat
Very
Extremely
Unable to Rate Suitability
Suitable
Suitable
Suitable
Unsuitable
Unsuitable
Unsuitable
Overall Suitability to the Profession
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