RSA Fellowship Application

RSA FELLOWSHIP NETWORK 2023

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 2023:*

First Last Credentials

PLEASE PROVIDE THE NAME OF THE PRACTICE/CLINIC YOU WILL BE WORKING AT IN JULY 2023:*

PLEASE PROVIDE THE ADDRESS OF THE PRACTICE/CLINIC YOU WILL BE WORKING AT IN JULY 2023:*

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 2023:

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 or More - I have personally performed more than 100 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 or More - I have personally performed 201 or more 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 or More - I have personally performed more than 100 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: 900 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.

Name

This field is for validation purposes and should be left unchanged.

*

RSA Fellowship Application - July 2023 - June 2025

*