JCAHPO Application for Examination
6. Responsibility Statement
JCAHPO's Responsibility for Certification and Recertification of Medical Personnel Performing Technical Ophthalmic Services for Ophthalmologists
JCAHPO is the federated organization of ophthalmological societies and associations which has been charged with certain responsibilities related to the education
and utilization of allied health personnel in ophthalmology. To implement these goals, JCAHPO has established criteria for training, examination, certification, and
utilization at various levels of expertise for Allied Ophthalmic Personnel.
Certification by JCAHPO indicates ONLY that the individual has fulfilled the eligibility requirements and successfully completed an examination for which the
individual qualifies. Certification by JCAHPO does NOT imply, by any criteria, that the individual is qualified as an independent practitioner.
AGREEMENT OF CERTIFICATION AND RECERTIFICATION
As an applicant for certification or recertification from JCAHPO, I agree to the following:
Numbers 1 and 2 applicable to COA, COT, COMT, OSA, CDOS, and ROUB applicants only.
1. I shall perform, to the best of my ability, those technical ophthalmic services specifically delegated to me by a sponsoring ophthalmologist/physician
according to his or her directions, instructions, and prescriptions.
2. I shall provide technical ophthalmic services only in the office of my sponsoring ophthalmologist/physician, a medical clinic, or other medical facility.
Number 3 applicable to CCOA applicants only
3. I am currently employed by a corporation that does business within the ophthalmic community and, in my position, I will be interacting with ophthalmic
professionals on a continuing basis.
Numbers 4-10 applicable to all applicants
4. I authorize JCAHPO to communicate any violation of its rules or standards by me, my status of application or certification, and any matter involving me to
state and federal authorities, employers, training programs, and others.
5. I agree not to make and to correct immediately any statements concerning my certification status which are or which become untrue or misleading.
I agree to provide JCAHPO confirmation as requested by JCAHPO.
6. I release JCAHPO, its officers, directors, agents, employers, committee members, and others for disciplinary action taken in good faith pursuant to the rules,
standards, procedures, and sanctions of JCAHPO.
7. I authorize JCAHPO in its discretion to request information concerning matters relevant to this application and my certification, recertification, and review
of certification.
8. I have received and read the rules, standards, procedures and sanctions of JCAHPO. I comply with and agree to be bound by them.
9. Please respond to the following questions:
o Yes o No
o Yes o No
o Yes o No
Have you ever had a certification or license suspended or revoked?
Have you ever been dismissed from a job because of alcohol or other drug dependency?
Have you ever been convicted of a crime?
If the answer to any question in Number 9 is "Yes,” include a statement of explanation with the application.
10. JCAHPO examinations are confidential and proprietary. The examination(s) are available to you, the examinee, soley for the purpose of assessing your
proficiency level in the content areas referenced in the examination(s) for which you are eligible. You are expressly prohibited from disclosing, publishing,
reproducing, or transmitting the examination(s) in any matter, in whole or in part, in any form or by any means, verbal or written, electronic or mechanical,
for any purpose. By signing this application you agree to the above disclosure statement. If you do not agree to the disclosure statement and do not sign the
application you will not be eligible to take any JCAHPO examinations.
I affirm that all statements made in the above application are true. (Sign and date b