JCAHPO Application for Examination
7. Employer
All applicants, other than CCOA applicants, complete section A. CCOA applicants complete section B.
SECTION A (for COA, COT, COMT, OSA, ROUB, and CDOS applicants)
Clinic Name
Clinic Address
City
State
Zip
Telephone FAX
Clinic Manager
First
M.I.
Last
Employer’s Practice Setting (Check all that apply)
o Private, Solo
o Private, Group: Number of Physicians o 2-5 o 6-10 o 11 or more
o Hospital Clinic or HMO
o University Clinic
o Other:______________________
Employer’s Main Subspecialty (Check only one)
o Cataract and IOL
o Comprehensive Ophthalmology o Contact Lenses
o Cornea and External Diseases
o Glaucoma
o Low Vision
o Neuro-Ophthalmology
o Ophthalmic Pathology
o Ophthalmic Plastic/Reconstructive Surgery
o Optical Dispensing
o Pediatric Ophthalmology/Strabismus
o Refractive Surgery
o Retina and Vitreous Disease
o Other: _______________________
Section B (for CCOA applicants only)
Supervisor's Name
First
M.I.
Last
Company Name
Main Company Address
Product or Service Provided
Supervisor’s E-Mail
Applicant’s Job Title
8. Sponsor/Employer Endorsement
SPONSORING OPHTHALMOLOGIST ENDORSEMENT (for COA, COT, COMT, OSA, ROUB, CDOS applicants only)
Please check ONE of the following: o The applicant works under my direct supervision. o The applicant has my sponsorship.
(The sponsoring ophthalmologist (or physician for ROUB or CDOS) attests that he/she knows the individual applicant, certifies that the individual is knowledgeable and
skilled in the field, and that the individual is working within established JCAHPO guidelines for allied ophthalmic personnel.)
I am an ophthalmologist (or physician for ROUB or CDOS), licensed to practice medicine in:_____________________________________________________________
State or Province My license number
X
Sponsor’s Signature
Sponsor's Name
Date
First
M.I.
Last
Clinic Name
Clinic Address
City
State
Zip
Country
Telephone FAX
EMPLOYER’S ENDORSEMENT (CCOA applicants only)
The employer/supervisor attests that he/she knows the individual applicant, certifies that the individual is knowledgeable and skilled in the field, and that the
individual is working within established JCAHPO guidelines.
X
Employer’s Signature
Date
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