CriteriaforCert_FULL.pdf | Page 38

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