Confidential Clinical Reference Form (Page 2 of 2) in pdf

Confidential Clinical Reference Form Page 2

Please indicate the percentage of time that the applicant spent (should total 100%):

Observing

Carrying out administrative or clerical tasks

Direct contact/participation interacting with clients

Other (please explain)

Overall, I would rank this applicant

compared to the pool of other volunteers I have supervised this year.

(E.g., 1/5; that is, the top volunteer of 5 volunteers I supervised this year.)

Overall, I would rank this applicant

compared to the pool of the other volunteers I have supervised in total.

(E.g., 3/15; that is, 3rd highest volunteer of 15 volunteers I have ever supervised.)

With the appropriate clinical and academic education and training, would you be comfortable with this applicant providing care to

one of your family members? Yes ____

No____

Possibly ____

Cannot Rate ____

Please include a separate written letter justifying the above rankings. If possible, comment on evidence of clinical reasoning, problem

solving and professionalism.

Dates of supervised volunteer experience: _____________________________

Total number of hours of experience/volunteering at your facility: _________

IMPORTANT:

Send this form directly to the Ontario Universities’ Application Centre at the address at the top of page 1. If you are willing to be

contacted about your assessment of this applicant, please provide an email address or a telephone number where you can be

reached during business hours.

Referee’s Signature

Date

Confidential Clinical Reference Form Page 2