Candidate Name: Click Here to Enter Text
FEBOS-CR Candidate Application 2018
Overview
Use this form to outline your current practice as well as your surgical experience, teaching experience and publications. To complete this form, click into a box and overwrite the text.
Please note this document is locked – you cannot click and type outside the boxes assigned for responses.
Candidate Name: Click here to enter text.
Institution/Practice Setting:
Current role/ job title / Click here and overwrite with current role. /Name of Institution / Click here and overwrite with institution where you work /
Head/ director of department / Click here and overwrite with head/director name /
Surgical Experience
Years in practice, post residency (minimum 5 years) / 00 /Total cataract surgeries performed without supervision in the last 5 years (minimum 1,000) / 000
Total cataract surgeries performed without supervision in last year / 000
Typical surgical practice:
(Click on the “Click to select” Statement, then select one of the following: N = No experience, E = Experience, M = Manage regularly, R = Referred to you by others.). Select all that apply.
Cataract
Phaco PCIOL / Click to select / Phaco + ACIOL / Click to select /Combined cataract surgery with glaucoma surgery / Click to select / Combined cataract surgery with corneal surgery / Click to select /
Combined cataract surgery with vitrectomy / Click to select / Cataract in primary zonular pathology / Click to select /
Planned or unplanned ECCE + PCIOL / Click to select / Scleral fixation / Click to select /
IOL exchange / Click to select / Phakic IOL / Click to select /
Angle supported IOL / Click to select / Iris supported IOL / Click to select /
Multifocal IOL / Click to select / Toric IOL / Click to select /
EDOF IOL / Click to select / Laser Assisted Cataract Surgery / Click to select /
Refractive
Corneal laser surgery / Click to select / Clear lens extraction/ refractive lens exchange / Click to select /Phakic IOLs / Click to select / Other (Identify below) / Click to select /
Click here and overwrite text with other refractive procedures you perform. /
Cases with complicating ocular comorbidity
(Click on the “Click to select” Statement, then select one of the following: N = No experience, E = Experience, M = Manage regularly, R = Referred to you by others.). Select all that apply.
Previous corneal refractive surgery / Click to select / Previous vitrectomy / Click to select /White / rock hard cataract / Click to select / Corneal pathologies / Click to select /
Pseudoexfoliation/ loose zonules / Click to select / Small pupil / Click to select /
Biometric outliers / Click to select / IFIS / Click to select /
Glaucoma / Click to select / Uveitis / Choose an item. /
Paediatric cataract / Choose an item. /
Your Complex Surgery Video
As part of your application, you have submitted a video of a complex surgery. Please provide some case details in the box below, and outline why you consider this case to be complex. This information will be shared with examiners. Do not include any patient-identifiable information.
Overwrite this text with:Some case details
Reasons why you consider this surgery to be complex
Teaching & Presentation Profile
Provide details of your teaching experience in the past 5 years only, in each of the following settings. Please include course title, presentation title/ subject and year. Please note: event websites may be reviewed to confirm the information entered here.
Scientific and medical associations, societies and international educational programmes, (please only use the box indicated to list sponsored programmes):
Include free papers and posters presented at local/national/international meetings. Please include whether you were/are invited faculty or course leader for these activities.
Local Meetings
Enter details in this box, overwrite this text: Local meeting presentations in past 5 years /National Meetings
Enter details in this box, overwrite this text: National meeting presentations in past 5 years /International Meetings
Enter details in this box, overwrite this text: International meeting presentations in past 5 years /Sponsored programmes/ Industry (Local, National or International):
Enter details in this box, overwrite this text: Sponsored/ Industry presentations in past 5 years /Publications in Past 5 years
Please highlight your name in the publication reference to identify where you are in the list of authors (1st, 2nd, final, etc.). Please note, SCOPUS may be used to confirm the information provided here.
Please list your 5 most important publications (maximum five)
Enter details in this box, overwrite this text… /Peer Reviewed publications in the past 5 years
Enter details in this box, overwrite this text… /Non-Peer Reviewed in the past 5 years
Enter details in this box, overwrite this text… /Page 1 of 4