IELTS Endorsement form continued

International English Language Testing System (IELTS) Exemption Application

Endorsement Form

This form is to be completed by the applicant’s Clinical Placement Supervisor, who has observed and is familiar with their English language competence in a clinical setting.

Clinical placement supervisors acting as endorsers for the purpose of an IELTS exemption application must speak English as a first language.

Three endorsements are required to accompany an IELTS exemption application.

APPLICANT’S DETAILS

This section to be completed by applicant

Application reference number: ______

Full name: ______

Previous name: ______

Date of Birth: ______

I agree that the OTBNZ may contact the clinical placement supervisor in respect of any aspect of this endorsement.

Signed: ______Date ______

CLINICAL PLACEMENT SUPERVISOR’S DETAILS

This section to be completed by the clinical placement supervisor

Name: ______

Position: ______

Employing company/organisation: ______

Contact details: ______

Telephone No: 9.00am – 5.00pm (including area codes) ______

Email: ______

How long was the clinical placement?: ______

In what capacity do you know the applicant?

______

______

______

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APPLICANT’S ENGLISH LANGUAGE COMPETENCY IN A CLINICAL SETTING

Please comment on the applicant’s English language competency in a clinical setting, in each of the following areas:

1  Reading eg. clinical documentation.

______

______

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______

2  Writing eg. clinical documentation/reports/ progress notes.

______

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3  Speaking eg. interviews/assessment/verbal reports/phone calls.

______

______

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4  Listening eg. client and colleague interactions, and multidisciplinary team.

______

______

______

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CLINICAL PLACEMENT SUPERVISOR’S DECLARATION

Any further comments:

·  I wish to make the following comments in respect of this applicant’s English language competency.

______

______

______

______

______

______

______

·  I agree that the OTBNZ may contact me on the phone number, and email address on page one.

·  I declare that I am not a relative of the applicant, do not live at the same address as the applicant, and that all the information I have provided is true and correct.

Signed: ______

Date: ______

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