Confidential Reference Questionnaire FORM : Loyalist College

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CICE 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 CICE 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: * Required
Title: * Required
Address: * Required
Street Address City State / Province / Region ZIP / Postal Code
Reference Email: * Required
How do you know this applicant? * Required
How long have you known this applicant? * Required
COMMUNICATION SKILLS
1. How likely is the applicant to communicate their needs? * Required
- Never
- Sometimes
- Always
Give an example:
2. Does the applicant follow written/verbal directions? * Required
- Never
- Sometimes
- Always
Give an example:
3. Does the applicant contribute positively in a group setting/situation? * Required
- Never
- Sometimes
- Always
Give an example:
PROFESSIONALISM
4. The applicant adapts well to changes in his/her environment or routine. * Required
- Never
- Sometimes
- Always
Give an example:
5. The applicant demonstrates tolerance of frustrating situations and takes actions to resolve them. * Required
- Never
- Sometimes
- Always
Give an example:
6. The applicant consistently attends classes/coop/work/volunteer on a regular basis. * Required
- Never
- Sometimes
- Always
Give an example:
7. The applicant accepts feedback and adjusts behaviour accordingly. * Required
- Never
- Sometimes
- Always
Give an example:
8. How much support does the applicant require?
a) Placement/Coop/Work/Volunteer * Required
- Independent
- Check-in only
- Constant
- NA
b) Academic Work (assignments and tests) * Required
- Independent
- Check-in only
- Constant
- NA
c) In Class (clarification, classroom management, prompts and focus) * Required
- Independent
- Check-in only
- Constant
- NA
9. Please list at least three of the applicant's academic/employment strengths and areas to be strengthened. * Required
Strengths Areas to be strenthened
10. What do you see as the applicant’s greatest challenge in attending the CICE program at Loyalist College? * Required
11. Does the applicant display any behaviors that could impact their full participation at Loyalist College? * Required
- Yes
- No
13. Why do you think this applicant is a good candidate for the CICE program? Please give two reasons.
Reason 1 * Required
Reason 2 * Required
SIGNATURE AND CONSENT
Signature of reference: * Required
First Last
Date * Required
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).
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