Institutional Federal Compliance Report 2021

APPENDIX A:

SUNY State College of Optometry RESIDENCY PROGRAM APPLICATION

Complete Name of Facility: __________________________________________________

Site Address: ______________________________________________________________

Site Phone #: ( )

Site Fax #: ( )______________

Supervisor Name: _____________________________________________

Supervisor Email: _____________________________________________

Supervisor Phone Number: ______________________________________

Website: _____________________________________

Please indicate those that will have a significant supervisory role with residents. Include degree and title (if applicable) Attach a copy of current CV.

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ______________________________________________________________________________________

Names and Degrees of Director and/or Chief of Staff or Equivalent

____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

PROFESSIONAL STAFF

Optometrist:

Number of: full-time

part-time ___

Ophthalmologists:

Number of: full-time

part-time

For Military facilities, indicate the length of time each optometrist has been assigned to the facility and whether the assignment/tour of duty is permanent or temporary.

Number of Ophthalmology residents:

Length of rotation through clinic: _________________

Number of Optometry Externs: _____________________________ From what school(s)? ______________________________

Number of: Optometric technicians/assistants _________________________ Other ancillary personnel (describe): ________________________________________________ Opticians

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