IOBP and Canadian Examiners in Optometry PRIOR LEARNING ASSESSMENT IN OPTOMETRY REGISTRATION FORM

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Ashley Lamb
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FOR IOBP OFFICE ONLY Date Received: Application #: Information Package Sent IOBP and Canadian Examiners in Optometry PRIOR LEARNING ASSESSMENT IN OPTOMETRY REGISTRATION FORM Prior Learning Assessment

1 FOR IOBP OFFICE ONLY Date Received: Application #: Information Package Sent IOBP and Canadian Examiners in Optometry PRIOR LEARNING ASSESSMENT IN OPTOMETRY REGISTRATION FORM Prior Learning Assessment September 2014 Administration Dates: September 11th Written Assessment 8:00am to 5:30pm September 12th Optometry Specific Language Assessment 12:30 pm to 3:30 pm. The communication assessment is a mandatory component for all new PLA candidates. Those challenging any portion of the PLA for a 2 nd time may re-attempt if they wish. September 12th - Clinical Orientation Session, time to be determined September 13 th & 14 th Clinical Assessments (morning or afternoon session on either day as assigned) Given (First) Name (Mr./Ms./Mrs.) Surname (Family) Name Address City Country Telephone Address Province/State Postal Code/Zip Date of Birth / / Day/Month/Year Canadian Citizenship/Residency Status Canadian Citizen Permanent Resident Convention Refugee Other(please specify) The address that you provide will be used for correspondence with you. Please ensure that you inform us in writing of any address change, including new telephone numbers and/or address. Name of Optometry School: Country: Year of Graduation: Degree Awarded: First Language Spoken: Language of Optometry Instruction: 1 of 6

2 IOBP and Canadian Examiners in Optometry Enclosed Fees 1 st Attempt at PLA 2 nd and final attempt at PLA If this is your first attempt at the PLA please If this is your second attempt at the PLA enclose two separate bank drafts or money please enclose separate bank drafts or money orders payable in Canadian Dollars made out orders payable in Canadian Dollars as as follows: appropriate: Written: Canadian Examiners in Optometry -$2600 Clinical: UWaterloo, School of Optometry & Vision Science - $1000 Written: Canadian Examiners in Optometry -$2600 Clinical: UWaterloo, School of Optometry & Vision Science - $1000 Language assessment: Please include with this application, a passport sized photo of yourself taken within the last 6 months. 2 of 6

3 Relevant and Applicable Policies The following policies are relevant to your application to participate in the Prior Learning Assessment (PLA) administered to determine your eligibility for the International Optometric Bridging Program (IOBP). Sharing of Information between Organizations Your personal information will be shared between the Canadian Examiners in Optometry (CEO), the International Optometric Bridging Program, any provincial or territorial optometric regulatory bodies that you have applied to, or other relevant third parties. The sharing of your personal information will only be for the purpose of facilitating the determination of your eligibility to participate in the International Optometric Bridging Program. Cancellation and Refunds Candidates who cancel their registration more than twenty one (21) days prior to the first day of a PLA administration will receive a refund of the fees paid less an administrative charge of $ each for the written and clinical portions of the PLA. Candidates wishing to cancel their registration must notify both the IOBP and the CEO in writing of a candidate's intention to cancel. Candidates who cancel within twenty one (21) days of the first day of a PLA administration date will not receive any reimbursement of their fees, unless exceptional and substantive circumstances are determined. Cancellation or rescheduling of an administration of the PLA as a result of natural disaster or other uncontrollable causes is at the discretion of the IOBP and the CEO. Neither the IOBP nor the CEO is responsible for a candidate s expenditures, losses, or damages in the event of cancellation or rescheduling. Accommodation for Disabilities Requests for specific accommodations on the clinical portion of the PLA must be sent to the IOBP and received no later than 30 days prior to the date of the clinical PLA component. Requests for specific accommodations on the written portion of the PLA must be sent to the CEO and received no later than 120 days prior to the date of the written PLA component. 3 of 6

4 Candidates with disabilities are accommodated in taking the PLA clinical component. Disabled candidates are responsible for including a notice of disability with their application. A notice of disability includes a complete description of the disability verified by a relevant independent authority (e.g. physician or psychologist) acceptable to the IOBP (for the Clinical Components) or to the CEO (for the written components). Candidates with disabilities are expected to outline their specific request for accommodation for the clinical and/or written component which must be supported by the relevant independent authority. The IOBP and the CEO reserve the right to determine the nature and extent of the accommodations to be made for a candidate s disability in order to preserve the validity of the assessment. I declare that all information contained in this application is correct and complete. I understand that misrepresentation of any of this information by me may result in the cancellation of my registration for the Prior Learning Assessment. Further, I acknowledge that I have read, understand and will abide by the Relevant and Applicable Policies listed above. Signature: Date: 4 of 6

5 PERSONAL DECLARATION I hereby give permission to Canadian Examiners in Optometry - Les Examinateurs Canadiens en Optométrie (CEO- ECO) and its officers and agents to release my performance results from the written Prior Learning Assessment (PLA) to a provincial or territorial optometric regulating body or to a relevant third party, such as the University of Waterloo School of Optometry and Vision Science s International Optometric Bridging Program (IOBP), the Ordre des Optometristes du Quebec, and/or the College of Optometrists of Ontario. I understand that CEO-ECO will not compensate me for costs in the event of a cancellation of an administration of the PLA if, in the sole discretion of CEO- ECO, there is justification to cancel an administration. I have reviewed the information about the written PLA and CEO- ECO at and the Examination Procedures, and I accept the terms and conditions of the examination to be administered by CEO-ECO. Signed: Date: 5 of 6

6 PRIOR LEARNING ASSESSMENT IN OPTOMETRY Clinical Session Questionnaire Candidate Name: Date: Listed below are some of the procedures being tested in the Clinical Prior Learning Assessment. Please indicate below (mark with an X) your comfort level with these procedures: Procedure Gonioscopy I feel comfortable performing this technique I do not feel comfortable performing this technique Goldmann Applanation Tonometry Hard Contact Lens insertion and removal Soft Contact Lens insertion and removal Please note that the above procedures involve a risk of harm to the patient if performed incorrectly. If you do not feel comfortable performing any of the above techniques, you will not be permitted to attempt them during your clinical assessment. Refraction: Standard procedure in Canada is to use a manual phoropter for refraction. You are welcome to do a trial frame/lens refraction during the assessment and will not be penalized for doing so. If you will require a trial frame and lenses you are required to bring your own. Registration will be considered complete when the fees, completed application form (pages 1 to 6), passport sized photo and questionnaire have been received. Please note: Original registration forms must be received. Faxed or ed registration forms will not be accepted. Page 6 of 6

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