RSA Fellowship Application – RSA Fellowship Network

RSA FELLOWSHIP NETWORK 2024
• Rolling Application Process - Now Accepting Applications for Our RSA Fellowship Network Positions Beginning in July 2024 through June 2026.

FULL NAME & CREDENTIALS:*
First Middle Last Credentials (MD, DO, MBBS, etc...)
DATE OF BIRTH*
GENDER*
PERSONAL EMAIL:*
Enter Email Confirm Email
PERSONAL CELL PHONE NUMBER:*
MARITAL STATUS*
HOME ADDRESS:*
Street Address City State / Province / Region ZIP / Postal Code Country
MEDICAL LICENSURE #1*
Medical License Number Effective Date State / Province / Region Country
DO YOU HAVE MORE THAN ONE MEDICAL LICENSE?*
MEDICAL LICENSURE #2*
Medical License Number Effective Date State / Province / Region Country
MEDICAL LICENSURE #3*
Medical License Number Effective Date State / Province / Region Country
MEDICAL LICENSURE #4*
Medical License Number Effective Date State / Province / Region Country
NAME OF PRACTICE/CLINIC YOU ARE CURRENTLY WORK AT:*
CURRENT PRACTICE/CLINIC PRACTICE ADDRESS:*
Street Address City State / Province / Region ZIP / Postal Code Country
CURRENT PRACTICE/CLINIC PRACTICE WEBSITE:*
IS THE CURRENT PRACTICE/CLINIC THE ONE YOU WILL WORK AT IF ACCEPTED INTO THE RSA FELLOWSHIP?*
- YES - The Practice/Clinic listed above is where I will be working for the RSA Fellowship Program, if accepted.
- NO - I will be working at a different Practice/Clinic, if accepted.
- NOT IDENTIFIED YET - I have not identified a Practice/Clinic nor a Preceptor, at this time for the RSA Fellowship Program.
PLEASE PROVIDE THE NAME OF THE PRECEPTOR YOU WILL BE WORKING FOR IN JULY 2024:*
First Last Credentials
PLEASE PROVIDE THE NAME OF THE PRACTICE/CLINIC YOU WILL BE WORKING AT IN JULY 2024:*
PLEASE PROVIDE THE ADDRESS OF THE PRACTICE/CLINIC YOU WILL BE WORKING AT IN JULY 2024:*
Street Address City State / Province / Region ZIP / Postal Code Country
PLEASE PROVIDE THE WEBSITE OF THE PRACTICE/CLINIC YOU WILL BE WORKING AT IN JULY 2024:
NUMBER OF LASIK SURGERIES YOU HAVE PERSONALLY PERFORMED:*
- None - I have not personally performed any LASIK surgeries at this time.
- 1 to 10 - I have personally performed between 1 and 10 LASIK surgeries at this time.
- 11 to 20 - I have personally performed between 11 and 20 LASIK surgeries at this time.
- 21 to 50 - I have personally performed between 21 and 50 LASIK surgeries at this time.
- 51 to 100 - I have personally performed between 51 and 100 LASIK surgeries at this time.
- 101 to 200 - I have personally performed between 101 and 200 LASIK surgeries at this time.
- 201 to 300 - I have personally performed between 201 and 300 LASIK surgeries at this time.
- 301 or More - I have personally performed more than 301 LASIK surgeries at this time.
NUMBER OF CATARACT SURGERIES I HAVE PERSONALLY PERFORMED:*
- None - I have not personally performed any cataract surgeries at this time.
- 1 to 20 - I have personally performed between 1 and 20 cataract surgeries at this time.
- 21 to 50 - I have personally performed between 21 and 50 cataract surgeries at this time.
- 51 to 100 - I have personally performed between 51 and 100 cataract surgeries at this time.
- 101 to 200 - I have personally performed between 101 and 200 cataract surgeries at this time.
- 201 to 300 - I have personally performed between 201 and 300 cataract surgeries at this time.
- 301 to 400 - I have personally performed between 301 and 400 cataract surgeries at this time.
- 401 to 500 - I have personally performed between 401 and 500 cataract surgeries at this time.
- 501 to 600 - I have personally performed between 501 and 600 cataract surgeries at this time.
- 601 to 750 - I have personally performed between 601 and 750 cataract surgeries at this time.
- 751 to 1,000 - I have personally performed between 751 and 1,000 cataract surgeries at this time.
- 1,001 to 1,500 - I have personally performed between 1,001 and 1,500 cataract surgeries at this time.
- 1,501 to 2,000 - I have personally performed between 1,501 and 2,000 cataract surgeries at this time.
- 2,001 to 2,500 - I have personally performed between 2,001 and 2,500 cataract surgeries at this time.
- 2,501 to 3,000 - I have personally performed between 2,501 and 3,000 cataract surgeries at this time.
- 3,000 or More - I have personally performed more than 3,000 cataract surgeries at this time.
NUMBER OF PREMIUM IOL SURGERIES I HAVE PERSONALLY PERFORMED:*
- None - I have not personally performed any premium IOL surgeries at this time.
- 1 to 20 - I have personally performed between 1 and 20 premium IOL surgeries at this time.
- 21 to 50 - I have personally performed between 21 and 50 premium IOL surgeries at this time.
- 51 to 100 - I have personally performed between 51 and 100 premium IOL surgeries at this time.
- 101 to 150 - I have personally performed between 101 and 150 premium IOL surgeries at this time.
- 151 to 200 - I have personally performed between 151 and 200 premium IOL surgeries at this time.
- 201 to 300 - I have personally performed between 201 and 300 premium IOL surgeries at this time.
- 301 to 400 - I have personally performed between 301 and 400 premium IOL surgeries at this time.
- 401 to 500 - I have personally performed between 401 and 500 premium IOL surgeries at this time.
- 501 or More - I have personally performed more than 501 premium IOL surgeries at this time.
HAVE YOU EVER BEEN CONVICTED OF A CRIME?*
PLEASE EXPLAIN THE CRIME(S) CONVICTION(S):*
ARE YOU CURRENTLY OR HAVE YOU BEEN INVOLVED IN A MEDICAL MALPRACTICE PROCEEDING?*
PLEASE EXPLAIN THE MEDICAL MALPRACTICE PROCEEDING:*
HAVE YOU EVER BEEN SUBJECT TO A PROFESSIONAL DISCIPLINARY PROCESS?*
PLEASE EXPLAIN THE INCIDENT(S) FOR YOUR PROFESSIONAL DISCIPLINARY ACTION:*
DO YOU HAVE ANY MEDICAL/DISABILITY CONSIDERATIONS WHICH MAY AFFECT YOUR ABILITY TO FULFILL THE RSA FELLOWSHIP REQUIREMENTS?*
PLEASE EXPLAIN YOUR MEDICAL/DISABILITY CONSIDERATIONS:*
ARE YOU WILLING AND ABLE TO TRAVEL FOR ONE TO FOUR WEEKS PER YEAR DURING THIS FELLOWSHIP PROGRAM?*
PLEASE EXPLAIN WHY YOU ARE UNWILLING/UNABLE TO TRAVEL DURING THE RSA FELLOWSHIP:*
ARE YOU APPLYING TO FELLOWSHIP PROGRAMS IN SPECIALTIES OTHER THAN REFRACTIVE SURGERY?*
PLEASE LIST THE OTHER FELLOWSHIP PROGRAM ARE YOU APPLYING TO:*
DO YOU HAVE ANY FOOD ALLERGIES OR SPECIAL DIETARY CONSIDERATIONS?*
MY FOOD ALLERGIES OR SPECIAL DIETARY CONSIDERATIONS ARE:*
UNDERGRADUATE UNIVERSITY*
Name University City/State Year Begun Year Graduated Degree Received Country
MEDICAL SCHOOL*
Name Medical School City/State Year Begun Year Graduated Degree Received Country
INTERNSHIP (enter N/A if you did not complete an Internship)*
Internship Name City, State & Country Year Begun Year Complete
RESIDENCY (enter N/A if you did not complete an Residency)*
Residency Name City, State & Country Year Begun Year Complete
OTHER GRADUATE SCHOOL DEGREE (Optional)
Name Graduate School City/State Year Begun Year Graduated/Graduating Degree Received Country
OTHER EDUCATION DEGREE/CERTIFICATION #1 (Optional)
Name Institution City/State Year Begun Year Graduated/Graduating Degree Received Country
OTHER ACCOMPLISHMENTS OR EXPERIENCE WE SHOULD BE AWARE OF? (Optional)

Please list any other accomplishments you feel we should be aware of here. These would include any honors, awards, research, publications, presentations, professional work experience, etc...
PLEASE DESCRIBE YOUR MOTIVATION FOR PURSUING A FELLOWSHIP POSITION IN THE RSA FELLOWSHIP NETWORK:*
PLEASE PROVIDE THE BEST DAYS(S) AND TIME(S) FOR A WEB INTERVIEW.*

Simply enter the day(s) of the week and the time of day that works best for your schedule. "Example Entry": Sundays from 9:00 AM - 5:00 PM EDT; Wednesdays from 5:00 PM - 9:00 PM EDT; Saturdays from 1:00 PM - 9:00 PM EDT
PLEASE UPLOAD YOU CURRICULUM VITAE AND A HEADSHOT / PHOTO*
Drop files here or

Max. file size: 12 MB.
I CONFIRM MY INTEREST IN COMPLETING THE ENTIRE 2-YEAR FELLOWSHIP PROGRAM*
- I CONFIRM MY INTEREST IN COMPLETING THE ENTIRE 2-YEAR FELLOWSHIP PROGRAM
RSA FELLOWSHIP NETWROK APPLICATION*
Today, I submit my application to the RSA Fellowship Network. I understand this program is a two-year program, which provides each Fellow with extensive training in clinical and surgical skills, awareness of the didactic elements of our procedures, and collaboration with the other fellows in the RSA Fellowship Network. There may also be the opportunity for high-quality business training, engagement in technology and innovation and teaching experience, and research.
Email
This field is for validation purposes and should be left unchanged.

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RSA Fellowship Application - July 2024 - June 2026

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