AOTA E.K. WISE SCHOLARSHIP: BUILDING A DIVERSE OCCUPATIONAL THERAPY WORKFORCE

Reference Form

TO BE COMPLETED BY THE PERSON MAKING THE RECOMMENDATION

NOTE: Please DO NOT submit Reference Letters or other attachments. Only this form will be considered by the reviewers.

The student above is applying for the AOTA E.K. Wise Scholarship, and has selected you to provide a reference. Please respond to the following on the applicant’s behalf.

1. How long have you known the applicant?

2. How well do you know the applicant?

Very Well

Fairly Well

Not Well

3. In what capacity have you known the applicant?

4. Please speak to the applicant's leadership and volunteer pursuits that you feel are significant in demonstrating the applicant’s qualifications, strengths, or accomplishments for being awarded this scholarship:

5. Please indicate the confidence with which you would or would not recommend the applicant for an AOTA E.K. Wise Scholarship:

Strongly Recommend

Recommend

Recommend with Reservations

Do Not Recommend

Signature:	Date:

Note. My electronic (typed) signature on this document constitutes my legal signature in accordance with 21 CFR Part 11: Electronic Records; Electronic Signatures Act

Please return this form to the student in order to complete the application process.