Confidential Reference Questionnaire This form must be filled out by a teacher, counsellor, employer, caseworker or someone who has extensive knowledge about the applicant, preferably in an academic or vocational setting. This form is not to be filled out by a family member or relative of the student applicant. Thank you in advance for filling out the Confidential Reference Questionnaire. Please answer all questions and be candid in your assessment of this applicant. Your comments are greatly appreciated. Please check the box that accurately describes the applicant’s typical behaviour or skill level. Student Applicant Name: * Required First Last Reference Name: * Required First Last Position: * RequiredTitle: * RequiredAddress: * Required Street Address City State / Province / Region ZIP / Postal Code Reference Email: * Required How do you know this applicant? * RequiredHow long have you known this applicant? Title: * RequiredCOMMUNICATION SKILLS1. The applicant communicates his or her needs or ideas effectively. * RequiredNeverSeldomSometimesFrequentlyAlwaysPlease specify the applicant’s preferred method of communication: (e.g. oral, sign language, electronic or other.)2. The applicant comprehends verbal direction: * RequiredWith Great DifficultyWith Some AssistanceIndependentlyComments:3. The applicant understands non-verbal communication (gestures, body language, tone of voice, etc.). * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:4. The applicant comprehends written instructions. * RequiredNeverSeldomSometimesFrequentlyAlwaysIn your estimation, what level of comprehension of written material does the applicant possess? (example: early primary, Grade 9...) * Required5. The applicant uses the telephone independently. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:SOCIAL SKILLS6. The applicant interacts cooperatively and productively on a one-to-one basis. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:7. The applicant interacts cooperatively and productively on a group basis. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:8. The applicant demonstrates acceptable social behaviour. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:9. The applicant adapts well to changes in his/her environment or routine. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:10. The applicant demonstrates tolerance of frustrating situations and takes actions to resolve them. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:11. The applicant generally displays predictable behaviour. * RequiredNeverSeldomSometimesFrequentlyAlwaysPlease explain your answer: * RequiredPERSONAL MANAGEMENT12. The applicant makes his or her own appointments when necessary. Always Always * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:13. a) The applicant remembers to keep appointments. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:b) Does the applicant effectively use an agenda or other planning device to ensure they meet deadlines and keep scheduled appointments? * RequiredYesNoType of planning device: * RequiredHe/she does not (effectively) use a planning device.YesNo14. Check all that apply. The applicant tells time using: * Required Analog clock Digital clock Cannot tell time 15. The applicant attends classes/work on a regular daily basis. * RequiredNeverSeldomSometimesFrequentlyAlwaysPlease clarify: * Required16. The applicant consistently attends classes/work on time. * RequiredNeverSeldomSometimesFrequentlyAlwaysPlease clarify: * Required17. The applicant works productively and completes assignments. * RequiredNeverSeldomSometimesFrequentlyAlwaysPlease clarify: * RequiredATTENDING/WORK SKILLS18. The applicant can attend to or be actively engaged through one, two or three consecutive 50-minute periods of class time. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:19. The applicant utilizes free time effectively. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:20. The applicant works independently on schoolwork and assignments when these are modified to be consistent with the applicant’s ability. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:21. a) During co-op or work experience, the applicant works with minimal supervision. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:b) CICE students attend field placement independently (without constant CICE staff support). Do you feel the applicant possesses the ability to attend field placement without direct, constant support? Explain. * Required22. The applicant uses a computer to complete basic word processing tasks. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:23. The applicant uses the internet independently. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:24. The applicant uses email independently. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:25. The applicant accepts feedback and adjusts behaviour accordingly. * RequiredNeverSeldomSometimesFrequentlyAlwaysComments:26. The applicant works in a safe manner and asks for assistance when necessary. * RequiredNeverSeldomSometimesFrequentlyAlwaysRELATED ITEMS27. Overall, the applicant has the ability to profit from a modified, integrated, two-year College program. * RequiredStrongly DisagreeDisagreeUndecidedAgreeStrongly AgreeComments:29. a) Please list at least three of the applicant's academic strengths: * Requiredb) Please list at least three of the applicant's academic areas to be strengthened. * Required30. Please comment on the level and type of support or modifications currently provided to the applicant on a regular basis. This support may be from educational assistants, SERT/AR, parents, tutors, caseworkers, workplace supervisors, etc. * Required31. What do you see as the greatest benefit for the applicant by attending the CICE program at Loyalist College? * Required32. What do you see as the applicant’s greatest challenge in attending the CICE program at Loyalist College? * Required33. Does the applicant display any behaviours which would prevent their full participation at Loyalist College? * RequiredSignature of reference: * Required First Last Date - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Consent * Required I agree to the privacy policy.By checking this box I agree to the best of my knowledge, this applicant has provided accurate information in this reference questionnaire.In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c, F.31, this is to advise you that the personal information on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and technology Act, 2002 and may be used and or disclosed for administrative, statistical and or research purposes of the College and or the ministries and agencies of the Government of Ontario and the Government of Canada, including but not limited to, tabulating and reporting data on Key Performance Indicators (graduate rate, graduate employment, graduate satisfaction and employer satisfaction).
