Disability Reference Assessment Form
Please complete this form to provide a reference assessment for an applicant requesting disability-related support. Your responses will help us understand the applicant’s context and support needs. All fields are required unless noted.
Applicant Full Name
*
First Name
Last Name
Applicant Email Address
*
example@example.com
Reference Full Name
*
First Name
Last Name
Reference Relationship to Applicant
*
Please Select
Teacher
Employer
Academic Advisor
Counselor
Other
How long have you known the applicant?
*
Please Select
Less than 6 months
6 months to 1 year
1–3 years
More than 3 years
In what context have you interacted with the applicant?
*
Assessment of Applicant’s Abilities and Needs
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Applicant communicates needs effectively
1
2
3
4
5
Applicant demonstrates resilience
6
7
8
9
10
Applicant requires additional support/accommodations
11
12
13
14
15
Applicant adapts well to new environments
16
17
18
19
20
How would you rate the applicant’s need for accommodations or support?
*
1
2
3
4
5
Would you recommend this applicant for disability-related support services?
*
Yes
No
Unsure
Additional Comments or Observations (optional)
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
Should be Empty: