ICO Fellowship Program Report of the Fellow RF

Fellow / Family Name(s)
First Name(s)
Age / Home Country
Fellowship / Subspecialty
Dates / Jan.Feb.Mar.Apr.MayJuneJulyAug.Sept.Oct.Nov.Dec., toJan.Feb.Mar.Apr.MayJuneJulyAug.Sept.Oct.Nov.Dec.,
Host
Supervisor
Training Center
City, Country
Sponsored by
Letter of thanks sent to donor? Copy to ICO?YesNo
Diploma received?YesNo
Pictures added to this report?YesNo
Overall impression?(click here to choose from drop-down-menu)excellentgoodaveragepoor
Did you meet your aimsYesNoMore or Less
Did you have hands-on patient contact?YesNo
Any communication / language problems?YesNo
Did you feel well-integrated?YesNoMore or Less

Please write a short report, considering the following points:
In what way were you involved in clinical activities, research activities, rounds, conferences, journal clubs, social events, etc.? Did you give presentations, for example?
What could you do practically with your own hands? Did you meet your aims?
What could be improved at your training center? Any other comments?

FELLOW AND PATIENT PERMISSION TO USE IMAGES ON WEBSITE OR PROMOTIONAL MATERIALS

The International Council of Ophthalmology (ICO) requests that fellows submit high-resolution photographs of themselves working with patients, either during or following a fellowship. These photographs may be taken while examining a patient, teaching a resident, or working in surgery. In such cases, the photographs may include the patient’s face.

Therefore, it is important for the patient and fellow to understand that submitted photographs are used in various non-commercial ICO materials, such as curriculum covers, brochures, program updates, and fundraising materials.

  • It is important for the fellow to make sure the patient understands that the photographs may be published for non-commercial purposes.
  • It is important for the fellow and the patient to understand that the photographs are important to ICO’s efforts to promote our educational materials and fundraise for the ICO Fellowships program. The ICO will not use the photographs for any commercial use.

As an ICO Fellow, please be certain that your patient has given his or her consent to have their image used in ICO print and online materials. If they are a minor (a child is usually defined as those who are under 18 years of age), please be sure that their care giver has given permission. Written permission is preferred, but is not required.

By receipt of photographs and other reporting materials, the ICO assumes that the fellow has obtained all required permissions.

Please direct any questions or concerns to r .

Photo Requests:

  • Please send your photos to or . You may also upload them through our online system:
  • Please be sure to include a document or name the file with any doctor names and the type of procedure (if applicable).
  • The ICO requests a selection of the photos be “action shots” of the fellow posed or actually doing surgical or assessment work. The photos can be surgical, research-based, or educational (teaching). These types of photos are invaluable for fellowship promotion and fundraising.

______

Place and Date. Signature.

Please print, sign (!) and scan+email or fax this form to the Fellowship Board. Please add pictures to your report! Report and/or pictures may be published in journals in order to promote the Fellowship Program.