Residency Manual

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

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