VERIFICATION AND RECOMMENDATION FORM FOR
JOB SHADOW/VOLUNTEER EXPERIENCE IN OT
greenriver.edu/ota • (253) 833-9111 Ext. 4839 • 12401 SE 320th St., Auburn, WA 98092
Green River College does not discriminate on the basis of race, creed, color, national origin, sex, sexual orientation, age, marital status, religion, disability, genetic information or on any other unlawful basis. The college is committed to
preventing and stopping discrimination, including harassment of any kind and any associated retaliatory behavior. The following person has been designated to handle inquiries regarding the non-discrimination policies: Vice President
of Human Resources, 12401 SE 320th Street, Auburn, WA 98092-3622, (253) 288-3320. To receive this information in an alternate format, please contact Disability Support Services at (253) 833-9111, ext. 2631; TTY (253) 288-3359.
TO BE COMPLETED BY THE APPLICANT
Name:
Address:
City: State: Zip:
Hours completed:
Select one: ❑ I waive the right to view this recommendation/verification form in my file at Greer River College.
❑ I do not wish to waive this right; I wish to retain the right to view this letter in my file at Green River College.
TO BE COMPLETED BY THE OCCUPATIONAL THERAPY PRACTITIONER
This section is to be completed by the occupational therapy practitioner who supervised the applicant’s job shadow, volunteer or paid
work experience. After completion, the form should be placed in a sealed envelope with the occupational therapy practitioner’s signature
across seal. The completed form should then be submitted with application packet.
Name: Discipline: ❑ OTR ❑ OTA ❑ Other:
Facility: Phone:
Address:
City: State: Zip:
1. I verify that this applicant has completed hours of job shadow/volunteer/paid work experience in the setting in which I work.
2. Please rate the applicant on a scale of 1 to 5 with 5 representing excellence and 1 representing unsatisfactory performance:
❑ 5 ❑ 4 ❑ 3 ❑ 2 ❑ 1 ❑ N/A Demonstrates interest in occupational therapy.
❑ 5 ❑ 4 ❑ 3 ❑ 2 ❑ 1 ❑ N/A Has a neat and clean appearance that is appropriate for clinical setting.
❑ 5 ❑ 4 ❑ 3 ❑ 2 ❑ 1 ❑ N/A Asks questions appropriately
❑ 5 ❑ 4 ❑ 3 ❑ 2 ❑ 1 ❑ N/A Communicates effectively with staff and patients
❑ 5 ❑ 4 ❑ 3 ❑ 2 ❑ 1 ❑ N/A Demonstrates initiative to increase learning
3. Please select only one of the following recommendations:
❑ I highly recommend this applicant for a career in OT
❑ I recommend this applicant for a career in OT
❑ I recommend this applicant for a career in OT with reservations
❑ I do not recommend this applicant for a career in OT
4. Comments:
Signature: Date:
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OTA Program Verification and Recommendation Form • 1 of 1
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