Appendix D - OSA Case Study Log
Initial Application for Examination – SA3 Eligibility
Name:_______________________________________________________________________JCAHPO ID#_______________________
Sponsor’s Endorsement: “I attest that____________________________________________ has performed the following case studies in a
satisfactory manner. He/she has met all quality and standard expectations.
State or Province________________________________________________ My License Number___________________________
Physician’s Signature______________________________________________________________ Date______________________
Appendix C
Please list your descriptions of 15 Category A ophthalmic surgical assisting cases below. Eligible cases are listed in Appendix C in the
Criteria for Certification & Recertification handbook.
Description of Procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
36
Date
Physician’s Signature