Institutional Federal Compliance Report 2021

EQUIPMENT AND SPACE AVAILABLE

Number of exam lanes: _________________________

Number of optometry exam rooms (other than exam lanes): ________________

Equipment available (include exam room equipment, ancillary equipment, specialty equipment):

EQUIPMENT

TYPE/SPECIFY/NUMBER

OPERATING HOURS

Day

Time

Day

Time

Monday Tuesday

_________________ _________________ _________________ _________________ _________________

Saturday Sunday

______________ ______________

Wednesday

Thursday

Friday

On Call Hours/Time: ____________________________________________________________________________

MULTI-DISCIPLINARY HEALTH SERVICES

If the optometry clinic is part of a larger, multi-disciplinary health facility, indicate which other services are provided in the clinic:

Specialty Medicine Clinics: Psychology

Diabetes

Psychiatry Neurology

Hypertension

Respiratory (describe) Dispensing pharmacy

Geriatric medicine

Rehabilitative medicine

__ Cardiovascular

General practice medicine ___Podiatry Internal medicine

___Other (list below)

Dentistry

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