FOR IOBP OFFICE ONLY Date Received: Application #:  Information Package Sent PRIOR LEARNING ASSESSMENT IN OPTOMETRY REGISTRATION FORM IOBP and Canadian Examiners in Optometry Prior Learning Assessment February 2015 Administration Dates: • Thursday February 5th, 2015 – Written Assessment 8:00am to 5:30pm • Friday February 6th, 2015 – Optometry Specific Language Assessment (OSLA). Time to be determined. The OSLA is a mandatory component for all new PLA candidates. Those challenging the PLA for a 2nd time may re-attempt if they wish. • Friday February 6th, 2015 - Clinical Component Orientation Session. Time to be determined. • Saturday February 7th, 2015 – Clinical Component (morning or afternoon session as assigned) Given (First) Name (Mr./Ms./Mrs.) Surname (Family) Name Address City Province/State Country Postal Code/Zip Telephone Date of Birth Email Address / / 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 email address. Name of Optometry School: __ Year of Graduation: ____________ First Language Spoken: _________________ ______________ Degree Awarded: ____ ____ Country:___________________ ________ Language of Optometry Instruction: _________ ________ IOBP and Canadian Examiners in Optometry Fees If this is your first or second attempt at the PLA please enclose two separate bank drafts or money orders payable in Canadian Dollars made out as follows: Written: Canadian Examiners in Optometry -$3500  Clinical Component: UWaterloo, School of Optometry & Vision Science - $1000  Optometry Specific Language Assessment Please note that results from the Optometry Specific Language Assessment (OSLA) will determine if further language training will be required as part of the bridging program. If this is your second attempt at the PLA and you wish to re-attempt the Optometry Specific Language Assessment (OSLA) please indicate so below. Optometry Specific Language Assessment: Yes  No   Please include with this application, a passport sized photo of yourself taken within the last 6 months. 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 twenty one (21) days or more prior to the first day of a PLA administration will receive a refund of the fees paid less an administrative charge of $150.00 each for the written and clinical Component 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 component of the PLA must be sent to the IOBP and received no later than 30 days prior to the date of the clinical component of the PLA. Requests for specific accommodations on the written component 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. Candidates with disabilities are accommodated in taking the clinical component of the PLA. 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 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:__________________ PERSONAL DECLARATION I hereby give permission to Canadian Examiners in Optometry - Les Examinateurs Canadiens en Optométrie (CEOECO) 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 CEOECO, there is justification to cancel an administration. I have reviewed the information about the written PLA and CEOECO at www.ceo-eco.org, and the Examination Procedures, and I accept the terms and conditions of the examination to be administered by CEO-ECO. Signed: Date: DÉCLARATION ET CONSENTEMENT DU CANDIDAT J’autorise, par la présente, les Examinateurs canadiens en optométrie (ECO), ses dirigeants et représentants à transmettre mes résultats à l’Évaluation des connaissances acquises (ECA) à une autorité réglementaire provinciale ou territoriale en optométrie, ou à un tiers concerné, tel que l’International Optometric Bridging Program (IOBP) de l’École d’optométrie et des sciences de la vision de l’Université de W aterloo, l’Ordre des optométristes du Québec et l’Ordre des optométristes de l’Ontario. Je comprends également que les ECO ne me rembourseront pas les dépenses engagées s’il advenait que l’ECA doive être annulée pour des raisons déterminées à l’entière discrétion des ECO. J’ai examiné attentivement l’information sur l’ECA, les procédures d’examen et les ECO publiée à l’adresse www.ceoeco.org et j’accepte les modalités et les conditions de l’examen administré par les ECO. Signed: Print Name: Date: PRIOR LEARNING ASSESSMENT IN OPTOMETRY Clinical Component Questionnaire Candidate Name: Date: ___________________ Listed below are some of the procedures being tested in the Clinical Component of the 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 the clinical component of the PLA. 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 this questionnaire have been received by the IOBP. Please note: Original registration forms must be received. Faxed or emailed registration forms will not be accepted. Page 6 of 6