VERIFICATION OF IMMERSION NATIONAL ORIENTATION AND MOBILITY CERTIFICATION (PLEASE

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Application

Verification of Immersion


National Orientation and Mobility Certification


(Please print clearly)


Applicant Name: Date:

First Last MI mm/dd/yyyy


VERIFICATION OF IMMERSION NATIONAL ORIENTATION AND MOBILITY CERTIFICATION (PLEASE

Immersion Information


Immersion Supervisor: Title:


Location: Dates:

From/To


Total Hours of Immersion:

Number of Days Hours per Day


Address: Phone:

Street Suite


E-mail:

City State Zip



Supervisor Verification


Please address each of the following questions. Include a separate document if you need to elaborate.


  1. Did the applicant learn non-visual skills, and is he/she able to demonstrate competent mastery of those skills?







  1. How would you characterize the applicant’s expressed attitudes regarding blindness?







  1. Did the applicant demonstrate an understanding of the effect that public attitudes about blindness has on blind people?







  1. How would you characterize the applicant’s overall philosophy about blindness?








  1. Were the applicant’s interactions with other staff and students appropriate? Are there any specific instances that might warrant further clarification?







  1. Do you feel that the applicant possesses the necessary skills, attitudes, and disposition to be a good cane travel instructor?





Do you recommend that this applicant pursue formal training to be a Structured Discovery Cane Travel Instructor?


I recommend this applicant without reservation


I recommend this applicant with reservations, as indicated below


I DO NOT recommend this applicant, as indicated below



Please describe the nature of your reservations or reasons for not recommending this applicant (use a separate sheet of paper if necessary).








I certify that the facts set forth in this form are true and complete to the best of my knowledge, and that I have filled out this form without regard to race, creed, color, religion, sex, age, disability, veteran status, or national origin.


Signed: Date:

mm/dd/yyyy


Please return this signed Verification of Immersion to the NBPCB, 101 S Trenton, Ruston, LA 71270. Alternatively, you may place this recommendation in an envelope, seal, sign across the seal, and return it to the applicant to submit with his/her application.


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