Preceptor Interest

PRECEPTOR INTEREST - FELLOW SELECTION PENDING

COMMITMENT LETTER

(Click Here) to review the Preceptor Commitment Letter for the participation in the RSA Fellowship Network 2022/2023.

By submitting this form, I express my interest as a Fellowship Preceptor in the RSA Fellowship Network. I have reviewed the Preceptor’s Invitation to Participate Letter Dated January 26, 2022, (Click Here to Download) and agree to the scope of the program when completing enrollment a Fellow in the RSA Fellowship Network should I identify one. I understand this program provides each Fellow with a unique “networked” format for the fellowship and entitles them to participate in extensive training in a virtual environment, as well as access to electives at other RSA clinical sites and other programs.

PRECEPTOR INFORMATION

FULL NAME & CREDENTIALS:*

First Middle Last Credentials (MD, DO, MBBS, etc...)

Certifying Board*

Please provide the name of the board which awarded your certification(s). i.e. ABO for American Board of Ophthalmology or MBBS for Bachelor of Medicine, Bachelor of Surgery.

Academic Appointments (if Any)

Please provide any Academic Appointments, Titles, etc...if any

PERSONAL EMAIL:*

Enter Email Confirm Email

PERSONAL CELL PHONE NUMBER:*

PRACTICE / SITE INFORMATION

Practice Name*

PRACTICE ADDRESS:*

Street Address City State / Province / Region ZIP / Postal Code Country

PRACTICE PHONE NUMBER:*

PRACTICE WEBSITE:*

HAVE YOU INTERVIEWED ANY CANDIDATES AS AN INCOMING 2022 FELLOW YET?*

No, Not Yet.
YES! Through the "Match" but no match was made.
YES! Independently, outside of the "Match", but an appropriate candidate was not located.
YES! Both through the "Match" and outside the "Match", but an appropriate candidate was not located.

PRACTICE INFORMATION

PROCEDURES PERFORMED AT MY PRACTICE*

To better understand the scope of your practice, please indicate the procedure offerings in your practice:

APPROXIMATE NUMBER OF CORNEAL REFRACTIVE PROCEDURES PERFORMED IN PRACTICE IN ONE YEAR*

APPROXIMATE NUMBER OF LENS BASED REFRACTIVE PROCEDURES PERFORMED IN PRACTICE IN ONE YEAR*

NUMBER OF SURGEONS IN PRACTICE*

ADMINISTRATIVE CONTACT INFORMATION

NAME OF ADMINSITRATIVE CONTACT @ PRACTICE*

Administrator Email Address*

Enter Email Confirm Email

DO YOU HAVE ANY COMMENTS OR QUESTIONS?

Name

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

*

RSA Fellowship Network - Preceptor Interest - Fellow Selection Pending