Jcahpo Application For Examination Form – Fill Out and Use This PDF

JCAHPO Application for Examination

6. Responsibility Statement

JCAHPO's Responsibility for Certiication and Recertiication of Medical Personnel Performing Technical Ophthalmic Services for Ophthalmologists

JCAHPO is the federated organization of ophthalmological societies and associations which has been charged with certain responsibilities related to the education and utilization of allied health personnel in ophthalmology. To implement these goals, JCAHPO has established criteria for training, examination, certiication, and

utilization at various levels of expertise for ophthalmic medical personnel.

Certiication by JCAHPO indicates ONLY that the individual has fulilled the eligibility requirements and successfully completed an examination for which the individual qualiies. Certiication by JCAHPO does NOT imply, by any criteria, that the individual is qualiied as an independent practitioner.

AGReeMeNT OF CeRTIFICATION AND ReCeRTIFICATION

As an applicant for certiication or recertiication from JCAHPO, I agree to the following:

Numbers 1 and 2 applicable to COA, COT, COMT, OSA, CDOS, and ROUB applicants only.

1.I shall perform, to the best of my ability, those technical ophthalmic services speciically delegated to me by a sponsoring ophthalmologist/physician according to his or her directions, instructions, and prescriptions.

2.I shall provide technical ophthalmic services only in the ofice of my sponsoring ophthalmologist/physician, a medical clinic, or other medical facility.

Number 3 applicable to CCOA applicants only

3.I am currently employed by a corporation that does business within the ophthalmic community and, in my position, I will be interacting with ophthalmic professionals on a continuing basis.

Numbers 4-10 applicable to all applicants

4.I authorize JCAHPO to communicate any violation of its rules or standards by me, my status of application or certiication, and any matter involving me to state and federal authorities, employers, training programs, and others.

5.I agree not to make and to correct immediately any statements concerning my certiication status which are or which become untrue or misleading. I agree to provide JCAHPO conirmation as requested by JCAHPO.

6.I release JCAHPO, its oficers, directors, agents, employers, committee members, and others for disciplinary action taken in good faith pursuant to the rules, standards, procedures, and sanctions of JCAHPO.

7.I authorize JCAHPO in its discretion to request information concerning matters relevant to this application and my certiication, recertiication, and review of certiication.

8.I have received and read the rules, standards, procedures and sanctions of JCAHPO. I comply with and agree to be bound by them.

9. Please respond to the following questions:

o Yes	o No	Have you ever had a certiication or license suspended or revoked?
o Yes	o No	Have you ever been dismissed from a job because of alcohol or other drug dependency?
o Yes	o No	Have you ever been convicted of a crime?

If the answer to any question in Number 9 is "Yes,” include a statement of explanation with the application.

10.JCAHPO examinations are conidential and proprietary. The examination(s) are available to you, the examinee, soley for the purpose of assessing your proiciency level in the content areas referenced in the examination(s) for which you are eligible. You are expressly prohibited from disclosing, publishing, reproducing, or transmitting the examination(s) in any matter, in whole or in part, in any form or by any means, verbal or written, electronic or mechanical, for any purpose. By signing this application you agree to the above disclosure statement. If you do not agree to the disclosure statement and do not sign the application you will not be eligible to take any JCAHPO examinations.

I afirm that all statements made in the above application are true. (Sign and date below.)

X

Applicant’s Signature

Date

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JCAHPO Application for Examination

9. Release of Examination Data

JCAHPO reserves the right to use, for any purpose, all examination data in aggregate reports related to exam performance. Release of such data will not include names or personal, identiiable information. Examples of the purposed, for which such data might be used include, but are not limited to: JCAHPO research

projects, grants, and formal training program reports.

Information regarding whether or not you are actively certiied is public and may be veriied or accessed by anyone.

If you wish to authorize JCAHPO’s release of your individual, identiiable data (name) to any source, please contact JCAHPO, in writing, with the name of the intended recipient and the time period in which release can be made.

Compliance with the Americans with Disabilities Act (ADA)

In compliance with the ADA, JCAHPO will provide reasonable accommodations for candidates with disabilities who cannot take the examination under the usual testing conditions. Disabled individuals must provide notice and appropriate documentation (at the applicant’s expense) of their disability when applying for the examination.

If accommodations are necessary for you to complete a JCAHPO examination due to functional limitations imposed by a disability, you will be required to complete and return a questionnaire. Questionnaires must be submitted with proper documentation and included with the examination application.

Application Checklist

Before mailing your application, please be sure that the following have been included:

oA copy of documentation showing successful completion of a formal educational training program or independent study course, if applicable.

oA copy of veriication of college credits or JCAHPO continuing education credits, if applicable.

oOSA applicants only: A copy of a document showing oficial accreditation of the surgical facility by a nationally-recognized accrediting agency, if using the

SA2 eligibility pathway.

oCompletion of the appropriate eligibility criteria box, question #9 on section 6, and your signature on application pages 1 and 2.

oCOA, COT, COMT, OSA, ROUB, and CDOS applicants: Your sponsor’s signature (application page 3 of 4). Your sponsor must be an ophthalmologist If you

are applying for the COA, COT, COMT, or OSA exam. ROUB and CDOS applicants may have any physician serve as their sponsor. Original signatures are required - signature stamps or computerized digitized signatures are not accepted.

oCOT or COMT applicants: If using the T4 or TG5 eligibility pathway, veriication of non-certiied work experience from your ophthalmologist on letterhead.

oCCOA applicants only: Your supervisor’s signature (application page 3 of 4). Original signatures are required - signature stamps or computerized digitized signatures are not accepted.

oCDOS applicants only: Case log of 10 abnormal ophthalmic B-scan examinations.

oExamination fee, payable to JCAHPO in U.S. dollars. (Refer to fee schedule). All applications denied due to not meeting the eligibility requirements or incomplete applications, will not receive a refund of the exam fee.

NOTe: Please retain a photocopy of your application. If any of the above-mentioned items are missing or

incomplete, your application will not be processed. Mail (DO NOT FAX) your application to:

JCAHPO

2025 Woodlane Drive

St. Paul, MN 55125-2998

Once your application is accepted, you will be assigned a 90-day eligibility period. You must schedule and take your examination during this period. This eligibility period, along with information on how to schedule your exam,

will be provided to you in a conirmation letter you will receive after your application is accepted.

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