"Prior Learning Self-assessment Form"

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Prior Learning Assessment: Self-Assessment Form

Full-Time

FCAPS

Student Number

Student Name

Course/ Program Name:

Course/ Program Code:

PLAR pre-application checklist.

I am 19 years of age or older OR I have an OSSD or equivalent

Yes

The course I am interested in is eligible for PLAR (check course outline)

Yes

This is my first application OR it has been one year (or longer) since I last attempted PLAR for this course

Yes

I have NOT failed or withdrawn from this course in the last year

Yes

If you answer “Yes” to all of these questions, you may proceed with your PLAR application

Critical Performance Statement

Learning Outcomes

For each learning outcome listed, please self-evaluate your competency levels and record in the appropriate column.

1. I am able to demonstrate the learning outcome well enough to teach it to someone else.

2. I can work independently to apply the learning outcome.

3. I need some assistance in using the outcome.

4. I am developing skills and knowledge for this area.

5. I have no experience with the outcome.

Level of Competence

Learning Outcomes

Experience ( eg Volunteer, hobbies,

3. Need

4. In

5. No

Documentation/ Evidence

project development)

Demo

Apply

Help

dev.

exp

Advisor Name: ________________________________

Signature: ____________________________________ Date: ___________________

Program Coordinator ____________________________________ Signature: ____________________________________ Date: ___________________

Referred to: Assessor ____________________________________

Bring the completed self-assessment to a consultation meeting with the program coordinator or faculty member.

Prior Learning Assessment: Self-Assessment Form

Full-Time

FCAPS

Student Number

Student Name

Course/ Program Name:

Course/ Program Code:

PLAR pre-application checklist.

I am 19 years of age or older OR I have an OSSD or equivalent

Yes

The course I am interested in is eligible for PLAR (check course outline)

Yes

This is my first application OR it has been one year (or longer) since I last attempted PLAR for this course

Yes

I have NOT failed or withdrawn from this course in the last year

Yes

If you answer “Yes” to all of these questions, you may proceed with your PLAR application

Critical Performance Statement

Learning Outcomes

For each learning outcome listed, please self-evaluate your competency levels and record in the appropriate column.

1. I am able to demonstrate the learning outcome well enough to teach it to someone else.

2. I can work independently to apply the learning outcome.

3. I need some assistance in using the outcome.

4. I am developing skills and knowledge for this area.

5. I have no experience with the outcome.

Level of Competence

Learning Outcomes

Experience ( eg Volunteer, hobbies,

3. Need

4. In

5. No

Documentation/ Evidence

project development)

Demo

Apply

Help

dev.

exp

Advisor Name: ________________________________

Signature: ____________________________________ Date: ___________________

Program Coordinator ____________________________________ Signature: ____________________________________ Date: ___________________

Referred to: Assessor ____________________________________

Bring the completed self-assessment to a consultation meeting with the program coordinator or faculty member.

PRIOR LEARNING ASSESSMENT APPLICATION

Please include the $110.64 (non-refundable) assessment fee with this application. Attach all supporting documents such as

portfolio, letters, résumés, etc. that apply to your request.

Full-Time

FCAPS

Student Number

Mr.

Surname

Given Names

Date of Birth (mm/dd/yyyy)

Mrs

Street Number and Name,

Apt. No.

P.O. Box, R.R. #

City/ Town

Prov.

Postal Code

Home Phone

Cell Phone

Email (Sheridan applicants and students:

If you are applying for postgraduate Nursing credits, please include your

we will

)

REGISTERED NURSING ONTARIO CERTIFICATE OF COMPETENCE NUMBER

communicate via your Sheridan email account

Course Title

Subject Code

Catalogue Number

Class Number

Program:

Source of Learning

Work Experience

Volunteer Work

Self Study

Seminars, etc.

Other:________________________________________________

Signature of Applicant _________________________________________________ Date ______________

FOR OFFICE USE ONLY

Approved:

Yes

Grade _____________ Entry Date _____________ Specialist’s Signature____________________________________

Assessor’s Name (please print)

Assessor’s Signature

Date

__________________________________

______________

Coordinator’s Name (please print)

Coordinator’s Signature

Date

__________________________________

______________

Information Acquired from the following sources:

Interview

Portfolio (documentation)

Challenge Exam

Samples of work

Demonstration

Other ________________________________________________

Assessor’s comments _____________________________________________________________________________________

_________________________________________________________________________________________________________

Payment received by: _________________________________________________________________________________

Freedom of Information and Protection of Privacy Act, 1987. The information on this form is collected under the legal authority of the Colleges and Universities Act, R.S.O. 1980,

C.272, s5: R.R.O. 1980, Reg. 640. This information will be used for the purpose of making admission and registration decisions, for communicating additional information about

College-wide activities, and for administrative and statistical purposes of the Ontario Ministry of Education and Training: For further information, please contact the Office of the

Registrar.

Prior Learning Assessment Waiver

This signed waiver gives permission to the Assessor to contact employers, co-workers, or references

named in my portfolio, on my resume or below in order that the sources of my documentation can be

verified.

Name (please print):_____________________________________________

Sheridan Student ID number (if applicable):___________________________

As per Section 39(1) of the Freedom of Information and Protection of Individual Privacy Act (FIPPA),

I,___________________________________________, authorize Sheridan to contact the persons or organizations

listed below to obtain reference information.

1. Name of Organization

Phone: Day

Contact:

Evening

Title:

Relationship to Reference:

2. Name of Organization

Phone: Day

Contact:

Evening

Title:

Relationship to Reference:

3. Name of Organization

Phone: Day

Contact:

Evening

Title:

Relationship to Reference:

Signature:_____________________________________________________

Date:_________________________________________

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"Prior Learning Self-assessment Form"

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