Appendix E - CDOS Case Log
CDOS Case Log - Initial Application for Examination
Name:_______________________________________________________________________JCAHPO ID#_______________________
Sponsor’s Endorsement: “I attest that____________________________________________ has performed B-Scan examinations in a
satisfactory manner. He/she has met all quality and standard expectations.
State or Province________________________________________________ My License Number___________________________
Physician’s Signature______________________________________________________________ Date______________________
Please note your case log of 20 abnormal ophthalmic B-Scan examinations, performed within 12 months prior to submitting your
application below:
At least five different pathologies must be listed. It is not necessary to submit the images.
Description of B-Scan Examination
Type of Pathology
Date
Sponsor’s Signature
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
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