Updated October 31, 2016

2017 EVALUATING EXAM REFERRAL FORM

Last (Family) Name: _____________________________ Given (First) Name: ______________________

Former Last Name (if applicable): _______________ Former First Name (if applicable): ________________

Please check (if applicable): □ PLA □ Evaluating Exam Date challenged (dd/mm/yy):

Gender: □ Male □ Female

Mailing Address:

Street Number: __________ Street Name: ________________________________________________________

Apt #: _______ City: _____________________ Province: _______________________

Country: ______________________ Postal Code: _______________________

Telephone number(s) (including country + city code): _____________________________________

E-mail address: __________________________________________________________

Acknowledgement and Consent I, ________________, agree to cooperate fully with the Federation of Optometric Regulatory Authorities of Canada (FORAC) (“FORAC”), and in particular:

1. I agree to provide FORAC with, or allow FORAC to obtain, program information regarding my international optometry-related

education.

2. I understand that FORAC and authorized persons acting on its behalf may contact any persons or organizations who may have

information that would assist FORAC and obtain information relevant to the pre-registration process. This includes the following:

Any educational institution (for example, the International Optometric Bridging Program (IOBP) and the University of Waterloo School of Optometry and Vision Science)

Any assessment, examination or credentialing agency or organization (for example, Touchstone Institute and Canadian Examiners in Optometry (CEO-ECO))

My previous or current employer(s)

Any governing or regulatory body

3. I consent to allowing FORAC to provide information to any persons or any organizations that may in any way, be relevant to my application for pre-registration and/or registration with the respective optometric regulatory body.

___________________________ _______________________ Candidate’s Signature Date (dd/mm/yy)

FOR FORAC USE ONLY

______________________ _______________ ______________________ ____________________________ Designated referral no. FORAC staff initials Date completed (dd/mm/yy) Date communicated to Touchstone Institute

For Prior Learning Assessment (PLA) Candidates ONLY – Candidates must complete the Form except for Section A. Section A is required to be completed by the International Optometric Bridging Program (IOBP) and followed by Canadian Examiners in Optometry (CEO-ECO) (if necessary). Acknowledgement and Consent I, __________________, consent to allowing any person authorized to act on behalf of the IOBP and CEO-ECO to provide the scores I achieved in all past written and clinical administrations of the Prior Learning Assessment (PLA) exams.

Candidate Full Name (please print)

Candidate Signature

Date (dd/mm/yy) Contact Information Last (Family) Name: _____________________________ Given (First) Name: ______________________ Former First Name (if applicable): _______________ Former Last Name (if applicable): ________________ Gender: □ Male □ Female

Mailing Address Street Number: __________ Street Name: ________________________________________________________ Apt #: _______ City: __________________ Province: ________________________ Country: __________________ Postal Code: __________________________________ Telephone (including country + city code): _____________________________________ E-mail address: ___________________________________________________________ To the Candidate: Once the above portion of the Form is completed, please provide the Form to the IOBP for completion of Section A. The IOBP is only to provide the Form to CEO-ECO if it does not have the PLA written results for the candidates. Once Section A is completed, the Form is to be sent directly by the IOBP or CEO-ECO, as applicable, to FORAC to forac.credentialing@gmail.com SECTION A: Prior Learning Assessment (PLA) Exam (to be completed by individual(s) authorized to act on behalf of the IOBP and CEO-ECO respectively, as applicable) Number of times above candidate attempted the PLA exam or portions of it: ____________ Please list PLA exam component score(s) achieved by above candidate: 1 a) Written: __________ on date (dd/mm/yy): _________ 1b) Clinical: Skill set 1:______Skill set 2:_______ Skill set 3:_______Skill set 4: ______ on date (dd/mm/yy): ________ 2a) Written: ___________ on date (dd/mm/yy): _________ 2b) Clinical: Skill set 1:______Skill set 2:_______ Skill set 3:_______Skill set 4: ______ on date (dd/mm/yy): ________ Comments: _______________________________________________________________________________

Initials of IOBP authorized individual

Initials of CEO-ECO authorized individual

2017 EVALUATING EXAM REFERRAL FORM

I, ________________ having been referred to TOUCHSTONE INSTITUTE to challenge the evaluating exam, understand that if I challenge the exam, I would be performing optometric procedures on standardized patients that if done inappropriately, could place the patient at risk. I hereby acknowledge that I have been educated and trained to perform the following procedures safely:

Check all that apply

1. Dilated fundus exam

2. Binocular indirect ophthalmoscopy

3. Contact Tonometry (i.e. Goldmann or Perkins)

4. Gonioscopy with fundus lenses

Signature Date: