THE OHIO STATE UNIVERSITY
                                                                                                      COLLEGE OF OPTOMETRY
                                                                                                      PERSONAL EVALUATION FORM

    To the Applicant:

    Please fill in the information requested below. Also, you must complete the waiver section if you choose to waive
    access to this evaluation. Then deliver this form directly to the person of your choice.

      Applicant's Information:
                 Last or Family Surname                                                  First                                             Middle

      Street Address: _______________________________________________________________________________________

      City, State, Zip ________________________________________________________________________________________

      Undergraduate Institution: ______________________________________________________________________________

      Email address: ______________________________________________________Phone # __________________________

       Evaluator's Information:


       Relationship to Applicant ________________________________________________________________________________

       Street Address: _______________________________________________________________________________________

       City, State, Zip ________________________________________________________________________________________

       Phone: _________________________________________________ Fax: ________________________________________

       Email: ______________________________________________________________________________________________

       Applicant's Waiver of Right to Access

       The Family Educational Rights and Privacy Act of 1974, as amended, (P.L. 93-380), allows a candidate for admission, employment, or receipt of honors to waive his
       or her right of access to confidential letters or statements written in his or her behalf if the recommendation is used solely for the purposes of admission, employment,
       or the receipt of honors and if the candidate, upon request, is notified of the names of all persons making such recommendations on his or her behalf. The university
       does not require that you make such a waiver as a condition for admission or award of fellowship or associateship. However, under the legislation you have the option
       of signing such a waiver as follows:

       I hereby waive my right to access to this evaluation and any appropriate attachments which have been written by

        _____________________________________________________ (insert name of evaluator) on behalf of my application to the OSU College of Optometry

       Printed Name: ____________________________________________ Date: _________________________ Signature: _____________________________________

                                                                                 Forward directly to:

                                                                             The Ohio State University
                                                                               College of Optometry
                                                                               Student Affairs Office
                                                                               A-424 Starling Loving
                                                                               338 W. 10th Avenue
                                                                              Columbus, Ohio 43210
The Ohio State University
Form 12155—Rev. 4/08                                                                   Next page
                                                                                                      The Ohio State University
                                                                                                      College of Optometry
                                                                                                      PERSONAL Evaluation Form

To the Person Completing This Form:

Applicant's Name: _____________________________________________________________________

Evaluator's Name: _____________________________________________________________________

The student named above has applied for admission to The Ohio State University College of Optometry. Please
complete this evaluation form and return it to the address indicated below. In addition to the form, you may also
submit a separate letter, however, we request that you complete and return this form, as the specific information
requested is very pertinent to our decision making process.

1. How long and how well have you known the applicant?

2. What opportunities have you had for observing the applicant in an optometric setting?

3. What is your opinion of the applicant's (please check one in each category):

                                    Exceptional*        Very Good           Good          Average         Below Average*          Unable to Comment






Communication Skills?


Interaction With Others?

*If these columns are checked, please provide explanation on a separate page.

4. In your opinion, does this applicant possess the motivation, dedication, and other qualities necessary to become a
successful optometrist? Please explain in detail.

5. If any of the foregoing information is from sources other than personal knowledge, please list the sources.

I certify that the answers given from personal knowledge are correct. If other sources of information have been used, they are only those which I believe
to be accurate and reliable.

Signature: _________________________________________________________Date: _________________________

                                                             The Ohio State University
                                                    College of Optometry, Student Affairs Office
                                                               A-424 Starling Loving
                                                                338 W. 10th Avenue
                                                              Columbus, Ohio 43210

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