CICE confidential reference questionnaire

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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:*
First Last
Reference Name:*
First Last
Position:*
Title:*
Address:*
Street Address City State / Province / Region ZIP / Postal Code
Reference Email:*
How do you know this applicant?*
How long have you known this applicant? Title:*
COMMUNICATION SKILLS
1. The applicant communicates his or her needs or ideas effectively.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Please specify the applicant’s preferred method of communication: (e.g. oral, sign language, electronic or other.)
2. The applicant comprehends verbal direction:*
- With Great Difficulty
- With Some Assistance
- Independently
Comments:
3. The applicant understands non-verbal communication (gestures, body language, tone of voice, etc.).*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
4. The applicant comprehends written instructions.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
In your estimation, what level of comprehension of written material does the applicant possess? (example: early primary, Grade 9…)*
5. The applicant uses the telephone independently.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
SOCIAL SKILLS
6. The applicant interacts cooperatively and productively on a one-to-one basis.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
7. The applicant interacts cooperatively and productively on a group basis.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
8. The applicant demonstrates acceptable social behaviour.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
9. The applicant adapts well to changes in his/her environment or routine.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
10. The applicant demonstrates tolerance of frustrating situations and takes actions to resolve them.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
11. The applicant generally displays predictable behaviour.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Please explain your answer:*
PERSONAL MANAGEMENT
12. The applicant makes his or her own appointments when necessary. Always Always*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
13. a) The applicant remembers to keep appointments.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
b) Does the applicant effectively use an agenda or other planning device to ensure they meet deadlines and keep scheduled appointments?*
- Yes
- No
Type of planning device:*
He/she does not (effectively) use a planning device.
- Yes
- No
14. Check all that apply. The applicant tells time using:*
- Analog clock
- Digital clock
- Cannot tell time
15. The applicant attends classes/work on a regular daily basis.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Please clarify:*
16. The applicant consistently attends classes/work on time.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Please clarify:*
17. The applicant works productively and completes assignments.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Please clarify:*
ATTENDING/WORK SKILLS
18. The applicant can attend to or be actively engaged through one, two or three consecutive 50-minute periods of class time.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
19. The applicant utilizes free time effectively.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
20. The applicant works independently on schoolwork and assignments when these are modified to be consistent with the applicant’s ability.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
21. a) During co-op or work experience, the applicant works with minimal supervision.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
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.*
22. The applicant uses a computer to complete basic word processing tasks.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
23. The applicant uses the internet independently.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
24. The applicant uses email independently.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
25. The applicant accepts feedback and adjusts behaviour accordingly.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
Comments:
26. The applicant works in a safe manner and asks for assistance when necessary.*
- Never
- Seldom
- Sometimes
- Frequently
- Always
RELATED ITEMS
27. Overall, the applicant has the ability to profit from a modified, integrated, two-year College program.*
- Strongly Disagree
- Disagree
- Undecided
- Agree
- Strongly Agree
Comments:
29. a) Please list at least three of the applicant's academic strengths:*
b) Please list at least three of the applicant's academic areas to be strengthened.*
30. 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.*
31. What do you see as the greatest benefit for the applicant by attending the CICE program at Loyalist College?*
32. What do you see as the applicant’s greatest challenge in attending the CICE program at Loyalist College?*
33. Does the applicant display any behaviours which would prevent their full participation at Loyalist College?*
Signature of reference:*
First Last
Date*
MM slash DD slash YYYY
Consent*
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.
CAPTCHA
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).

CICE confidential reference questionnaire

Confidential Reference Questionnaire

COMMUNICATION SKILLS

SOCIAL SKILLS

PERSONAL MANAGEMENT

ATTENDING/WORK SKILLS

RELATED ITEMS

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