ILLINOIS COLLEGE OF OPTOMETRY · Primary eye care practices are defined as practices where students interact with practitioners who provide, at least in part, full-scope optometry

ILLINOIS COLLEGE OF OPTOMETRY Department of Community Based Education

3241 South Michigan Avenue

Chicago, IL 60616-3878

Phone: 888-626-4025 (outside Illinois) or 312-949-7310

Thank you very much for your inquiry into the externship program at the Illinois College of

Optometry. We are always delighted to see interest in the optometry educational process in various

aspects of practice. Since our students will have many modes of optometry as an option for practice,

externship experiences in different types of practice are highly desirable. The Illinois College of

Optometry is certainly in the process of expanding its Community Based Education opportunities for

fourth year students. In the past several years, we have joined with practitioners in hospital, military,

multi-disciplinary and private practices to allow our students to experience the many facets of

optometry in a variety of settings. Our current community based facilities provide a wide variety of

primary eye care and pre- and post-operative care experiences. We also have a group of sites that

provide some low vision rehabilitation, contact lens and pediatric/binocular vision patient encounters.

Currently we are looking for situations where our students can experience some of these more

specialized forms of optometric practice such as contact lenses, low vision rehabilitation, and/or

pediatrics/binocular vision in multi-practitioner situations.

Basic requirements for all doctors (OD, MD, DO) who wish to participate in the precepting of ICO

fourth year externship students are as follows:

Must be a multi-doctor, at least two optometrists, facility/practice, must either be residency trained or

have more than five years of clinical experience, must have valid license to practice your profession,

must have current professional liability insurance and must not have any current or pending

malpractice claims against you or your facility/practice. You must be willing to accept a student

every quarter of the academic year and you must agree to participate for a minimum of three years.

Family members and/or relatives of current ICO students may not participate in the externship

program due to concerns of conflict of interest.

After you have considered the information provided, and if you are interested in pursuing the next

step toward participating in the education of optometry students at your facility, please fill out the

application data sheet provided toward the end of your packet. Return it, along with the requested

documentation for those practitioners who would potentially be working with students, to the

Department of Community Based Education. We will review the information and contact you

concerning a preliminary site visit if needed. Please note that site selection is student dependent so

there is no guarantee that you will have a student every quarter or every year.

Again, thank you for your interest in our community based educational program. If you have any

questions, please do not hesitate to call me.

Sincerely,

Brian Caden, O.D., M.A.,F.A.A.O.

Assistant Dean for Community Based Education

Illinois College of Optometry

(312) 949-7277/ (888) 626-4025

[email protected]

mailto:[email protected]

ILLINOIS COLLEGE OF OPTOMETRY Department of Community-based Education




Community Based Education: Private Practice Site Selection Criteria

Goals:

1. To utilize the opportunities available in private optometric practice for the education of Illinois

College of Optometry student clinicians.

2. To enhance and expand the diversity of patient populations available for community based

education.

3. To minimize the concerns of fully incorporating an educational situation into a revenue driven

organization.

Background:

1. In the near past, the community based education program utilized mainly Veterans

Administration Medical Centers, military bases, referral centers and hospital based sites for the

off campus educational experiences of our students primarily due to the presence of established

educational departments and/or mission statements. These sites continue to be welcomed into the

community-based education program.

2. Through the expansion of the current program, many private practices were successfully added to

the community-based network of the Illinois College of Optometry.

3. This incorporation of private practice, in combination with the established network of veteran’s

administration, military and Indian Health Services facilities, form an outstanding educational

forum for the students at the Illinois College of Optometry.

4. The assignment of curriculum hours to each external facility has allowed students the opportunity

to experience all types of diverse patient encounters within high quality clinical education

situations.

5. With the combination of traditional and non-traditional educational situations; the opportunity to

expand, in a controlled manner; and the duty to develop and refine common goals toward the

proposed future union of private and educational optometric sectors must be kept in mind at all

times. To that effort we incorporate a continuous feedback for improvement mechanism as well

as maintain an all out effort in support of our community based educational facilities.

Curriculum Requirements:

1. Private practices exist in a multitude of forms. Educational needs are based on the current

composition of community based facilities. These show an abundance of primary care type

patient populations, both those comprised of mainly ocular disease patients (VA’s) and routine

yet diverse patient populations (military bases). Because of these established, educational sound

and tested sites, basic primary eye care sites are needed less to balance the makeup of external

facilities available to fulfill the goal of diversity of patient encounters.

2. Due to an initial pilot project, pre- and post-operative care facilities, in which time spent with

both optometrists and various ophthalmology specialists, are now in an abundance for the

community based education pool.

3. Areas which are to a lesser extent fulfilled by the current full time community based facilities are

low vision rehabilitation, contact lenses fitting; and pediatric/binocular vision are now being

sought to expand the variety of community-based sites available to the student clinicians at the

Illinois College of Optometry. It is our contention that experiencing these specialized areas of

optometry in the private sector demonstrates the variety of modern optometry opportunities

available to the practitioners they will become.

4. Primary eye care practices are defined as practices where students interact with practitioners

who provide, at least in part, full-scope optometry care within the patient care setting. It is

recognized that many primary eye care practices also provide a strong emphasis in one of the

specialized areas of optometry listed. This is actually preferred as an educational setting as

variety and diversity are goals of the community based education program.

a. Primary eye care practices satisfy several different educational needs including a variety and

diversity of patient encounters.

b. These practices are selected due to educational considerations including balancing the

responsibilities of student precepting, student evaluations, and built-in scheduling reserves.

Therefore, each practice must be made up of at least two practitioners, although both not

necessarily specialize in primary eye care, to provide the desired clinical educational needs.

The further consideration of practice philosophy is taken into account so as not to frustrate

the practitioner who might feel the need to “re-teach” the student nor confuse the student who

has been presented with a common but not universal approach toward this patient population.

5. Multi-disciplinary practices are defined as OD/MD practices where students interact, at least in

part, with specialized optometrists, specialized ophthalmologists, and other specialized caregivers

for secondary and tertiary eye care within the patient care setting. It is recognized that many

multi-disciplinary practices also provide a strong emphasis in either primary eye care or one of

the other specialized areas of optometry listed. This is actually preferred as an educational

setting as variety and diversity are goals of the community based education program.

a. Multi-disciplinary practices satisfy several different educational needs including experience

with pre and post operative care as well as pathology referrals, providing variety and

diversity in patient type encounters.

b. Multi-practitioner offices are selected due to educational considerations including balancing

the responsibilities of student precepting, student evaluations, and built-in scheduling

reserves. Additionally, these offices most often incorporate several well-developed clinicians

having the patient care experience desired for a student’s clinical educational needs.

c. Each office must have at least one OD as a practitioner within the office setting. While

optometry and medicine have fairly similar educational philosophies, there are some distinct

differences. An OD, by training, is more aware of the educational expectations of a fourth

year clinician. The further consideration of practice philosophy is taken so as not to frustrate

the practitioner who might feel the need to “re-teach” the student nor confuse the student

who has been presented with a common but not universal approach toward this patient

population.

6. Contact lens practices are defined as those where students interact with practitioners who

specialize in and provide, at least in part, various types of contact lens fittings within the patient

care setting. It is recognized that many contact lens practices also provide a strong emphasis in

primary eye care or one of the other specialized areas of optometry listed. This is actually

preferred as an educational setting as variety and diversity are goals of the community based

education program.

a. Contact lens practices satisfy several different educational needs including having the

resources to provide the student with an entry to practice understanding of contact lens fitting

and corneal findings. For many of our students this will be their only exposure to contact lens

fitting and management.



Therefore, each practice must be made up of at least two practitioners, although both not

necessarily specialize in contact lens fitting, to provide the desired clinical educational needs.

The further consideration of practice philosophy is taken so as not to frustrate the practitioner

who might feel the need to “re-teach” the student nor confuse the student who has been

presented with a common, but not universal approach toward this patient population.

7. Pediatrics/Binocular vision practices are defined as those where students interact with

practitioners who specialize in and provide, at least in part, both pediatric primary eye care and

binocular vision therapy within the patient care setting. It is recognized that many

pediatric/binocular vision practices also provide a strong emphasis in primary eye care or one of

the other specialized areas of optometry listed. This is actually preferred as an educational

setting as variety and diversity are goals of the community based education program.

a. Pediatric/Binocular vision practices satisfy several different educational needs including

having the resources to provide the student with an entry to practice understanding of the

needs of pediatric patients as well as the utilization of binocular vision therapy for the benefit

of certain patient diagnoses.



Therefore, each practice must be made up of at least two practitioners, although both need

not necessarily specialize in pediatrics/binocular vision therapy, to provide the desired

clinical educational needs. The further consideration of practice philosophy is taken so as not

to frustrate the practitioner who might feel the need to “re-teach” the student nor confuse the

student who has been presented with a common but not universal approach toward this

patient population.

8. Low vision rehabilitation practices are defined as those where students interact with

practitioners who specialize in and provide, at least in part, low vision care within the patient care

setting. It is recognized that many low vision rehabilitation practices also provide a strong

emphasis in primary eye care or one of the other specialized areas of optometry listed. This is

actually preferred as an educational setting as variety and diversity are goals of the community

based education program.

a. Low vision rehabilitation practices satisfy several different educational needs including

having the resources to provide the student with an entry to practice understanding of the

needs of low vision patients as well as the utilization of devices and other modalities of

treatment for the benefit of certain patient diagnoses.



Therefore, each practice must be made up of at least two practitioners, although both need

not necessarily specialize in low vision rehabilitation, to provide the desired clinical

educational needs. The further consideration of practice philosophy is taken so as not to

frustrate the practitioner who might feel the need to “re-teach” the student nor confuse the

student who has been presented with a common but not universal approach toward this

patient population.

9. Optometry laws within a given region including scope of practice as well as guidelines for a

supervised but non-licensed clinician must be taken into account by any practice considering

entering into an externship affiliation. All practices considering incorporating a student into their

practice should consult their regional optometry laws and may even wish to inquire of their

Licensing and/or Governing Boards.

10. Only those practices expressing a commitment to completely integrate the student into the

process of patient diagnosis and management in a full-scope care setting should consider

application since it is our utmost responsibility to educate the student, not simply increase patient

contacts.

Process:

1. Practices that fit the above criteria may be referred to or sought out by the Assistant Dean for

Community Based Education.

2. A preliminary questionnaire will be sent out to gather information on educational opportunity and

basic living concerns of the students who would potentially be assigned. Information will be

obtained about the make-up of the patient population and those practitioners interested in

incorporating a student into it.

3. The practice will undergo a site visit to establish the nature of the daily routine and facilitate the

incorporation of the educational process into the day to day operation of the clinic if required.

4. Utilizing the criteria listed above, educational affiliations with those sites selected will be created.

5. Available students will then be offered the opportunity of rotation.

6. There will be careful monitoring and support to ease the incorporation of educating the student

clinician as well as constant feedback to enhance the educational program at each facility. These

include periodic site visits, program evaluation, student feedback, and faculty development.

7. Students may not be interviewed or screened prior to choosing a site, as all sites are open to any

fourth year student in good academic standing according to college policy.

8. If you are selected to be a site for our externship program, you will be given the title of preceptor

for our program. After a year of participation, you may apply to become an adjunct faculty

member of ICO by contacting the Community Based Education office for an application. If

approved, you will receive a letter of appointment from the Dean.





Optometric Student Procedures:

The student may, in conjunction with an attending optometrist/physician perform the following

procedures:

A. Comprehensive medical eye examination, diagnosis and treatment on an outpatient and/or

inpatient basis which may include, but is not limited to:

History

Visual acuity

Cover testing

Color vision

Stereopsis

Confrontation fields

Pupil testing

Extraocular muscle testing

Keratometry

Refraction

Appropriate near point testing (in and out of phoropter)

Biomicroscopy

Tonometry

Direct and indirect ophthalmoscopy

B. Gonioscopy

C. Visual fields

D. Use of instruments and pharmaceutical agents(diagnostic, topical and oral drugs) to evaluate

and treat the eye, adnexa, and related structures.

E. Foreign body removal (anterior segment).

F. Co-management of pre- and post-surgical patients.

G. Photo-documentation of the eye, adnexa and related structures.

H. Fluorescein angiography photography.

I. Dilation and irrigation of lacrimal system.

J. Evaluation and management of routine and complex refractive patients.

K. Evaluation and management of ocular diseases, including glaucoma, iritis, conjunctivitis,

blepharitis, and similar conditions.

L. Evaluation and management of contact lens patients.

M. Evaluation and management of vision therapy patients.

N. Evaluation and management of low vision patients.

O. Evaluation and management of eye injuries and emergencies.

P. Refer patients when appropriate to affiliated health care providers for patient care and

management of ocular or visual conditions or abnormalities.

Q. Insertion/Removal of punctal plugs.

R. Injections: intramuscular,subcutaneous,intradermal,IV, intralesional(eyelid) and

subconjunctival.

ILLINOIS COLLEGE OF OPTOMETRY 3241 South Michigan Avenue

Chicago, Illinois 60616-3878

Phone: 312-949-7310 /888-626-4025

Community-Based Education Department

Academic Year 2013-14

Patient Care Externship – CLE 485.1 (CLE 485.2; CLE 485.3; CLE 485.4) Approximately 40 hours of contact per week/20 hours of course credit per quarter

Department of Community Based Education: Dr. Brian Caden,Assistant Dean

Ms. Lisa Hamlin, Patient Care

Education Coordinator Phone: 888-626-4025 (Outside Illinois) or 312-949-7310

Fax: 312-949-7749

E-Mail: [email protected] and [email protected]

Course Description & Prerequisites During their fourth year of training students at the Illinois College of Optometry may be

assigned to two or more community based clinical experiences. These quarterly rotations last for

approximately 11 weeks (one quarter) and are performed within a variety of approved clinics within

the Chicago metropolitan area and other US cities. Many of the participating facilities are

multidisciplinary in nature and provide a hospital-based or outpatient setting for the delivery of

optometric training. Pre-requisite for assignment to a clinical externship is successful completion of

the educational elements pertaining to the first three years of the optometric curriculum provided at

the Illinois College of Optometry. All students assigned to clinical externship must also be

considered in “good standing” by the College.

Objectives The main objective of the Patient Care Externship is to add diversity to the fourth year student’s

training and to provide insight into other patient care environments. Other, more specific educational

objectives are listed below. The appropriate level of performance pertaining to these objectives will

vary depending on the specific quarter of assignment as well as a student’s prior clinical assignments.

1. To maintain and further develop an appropriate professional presentation toward patient care.

2. To develop appropriate patient communication and interpersonal skills.

3. To develop appropriate case documentation and patient-related correspondence skills.

4. To develop appropriate history taking skills.

5. To develop appropriate technical skills related to the ophthalmic examination and otherwise.

6. To develop appropriate test selection skills related to the ophthalmic examination.

7. To develop appropriate skills related to data analysis.

8. To reinforce and further develop the student’s knowledge base to an appropriate level.

9. To develop the appropriate skills related to case management.

10. To show demonstration of an appropriate level of interaction and activity pertaining to patient

related discussions, assignments, conferences, journal clubs, lectures, or similar activities.



Grading Policy You will be required to complete both a mid-quarter and final evaluation for each student

in your practice. You will be given a log in name and a password so that you may use the web

based site called Meditrek. Only one doctor, usually the contact person for the student, will be

given this information. There are seven categories to evaluate. They are: case history,

technical skills, test selection, data analysis, case management, knowledge base and case

documentation. An Honors score equals 12 points, Satisfactory equals 9 points and

Unsatisfactory equals 0 points. There are four additional categories to score. They are

efficiency, professionalism, patient communication and conference. They are graded as Above

Expected( 4 points),Expected(3 points), and Below Expected(0 points). Meditrek will e-mail

you to complete the evaluations at an expected due date.

Introductory letter assignment

At least three weeks prior to the start of the quarter, each student will be required to write a

letter of introduction to the site preceptor as part of the externship assignment. In it, all or at least

most of the following information should be included: why the site was chosen and what is most

interesting about it; clinical history – where and when assigned to other clinics (IEI and other

external rotations); goals for the rotation – what the student wishes to get from this experience – both

assigned activities expected and other interests should they be available; specific areas to improve by

the end of the quarter; what will be brought to this site – attitudes, clinical or experiences, etc.; post-

graduation goals and how might this rotation’s experiences fit into those goals; and concerns or

expectations about the program.

Other topics for the letter include housing issues, check-in, or time-off requests. Time Off

Approval Forms are available through the Department of Community Based Education and must be

processed through the Office. A copy of the student letter will be kept on file in the Community

Based Education office as well. The student may send the letter to you by mail, e-mail or fax to your

office.

Conduct Policy

While on externship students are expected to adhere to the rules and regulations stipulated by

individual externship facilities as well as the College’s code of conduct and ethics. Students are also

expected to meet critical standards of clinical performance within individual facility operations.

Failure to do so can result in dismissal from externship with reassignment to the Illinois Eye Institute

or elsewhere.

Attendance Policy Externs are to follow holiday/vacation schedules as stipulated by each individual externship

site unless specified within the “External Clinical Rotations” calendar published by the College.

Therefore externs do not necessarily follow the same clinic schedule as the Illinois Eye Institute on-

campus clinic. For those vacation periods specifically listed on the “External Clinical Rotations”

calendar, externs will be excused from their off-campus, patient care externships. Compensatory

days will not be given to students for missing on-campus College recess periods because of an

external rotation. Excused absences, such as travel/make-up weeks and NBEO Part II (Winter

quarter) and Part III are noted on the Academic Calendar sent to all site preceptors. ALL OTHER

ABSENCES MUST BE APPROVED THROUGH THE COMMUNITY BASED EDUCATION

DEPARTMENT. Time-off forms are available from the ICO Portal and should be promptly

completed by the student and signed by the preceptor.

When foreseeable, students should arrange for absences by contacting their site preceptor

several weeks prior to the needed time off. Built into the student schedule is a week between each

rotation. Absences should be made-up during these weeks if no other time exists in the clinic’s

schedule. The College MUST be notified of ALL absences.

Patient Log / Final summary and evaluation

Students are required to keep a consistent and formulated patient log during their externship

rotation to determine the number and types of patients encountered. They will be using an electronic

log supplied by meditrek.com. Any information collected about patients seen is in keeping with

HIPAA policy.

Housing Policy Students will be responsible for securing and maintaining place of residence while attending

out-of-town clinical externship rotations. Although certain externship facilities do fortunately

provide the extern with housing at either no cost or subsidized cost, this cannot be expected in most

situations. In instances where lodging is not provided by the externship facility, externs will be

expected to make arrangements for lodging in advance of the assigned clinical rotation. We strongly

encourage clinical preceptors to assist in this housing search as much as is possible. Where housing

has been arranged by externship facilities, lodging can be expected to be quite variable in regards to

distance from the externship clinic, cost to the student, and furnishings. In situations where lodging

has been arranged, the College cannot be expected to be responsible for the extern’s personal

belongings in the event of fire, theft, etc. Externs will be expected to follow any and all rules set

forth by the providing facility. Refusal to obey guidelines or neglect of properties provided by an

externship facility is grounds for immediate dismissal from an externship clinical rotation.

Student Employment and Externships

Because of potential confusion as to the role of optometrists-in-training and technician,

students who are working within a site affiliated with the College as a community-based education

facility are not eligible to be assigned to that site as an externship. Additionally, students may not be

paid as an employee by the facility during their externship assignments for their CLINICAL

assignments. They may not be used to perform work routinely performed by office staff. Students

are allowed to accept housing, travel and meal stipends as long as the Assistant Dean for

Community-Based Education is made aware of these arrangements in advance so that it is

determined that these stipends are fair and equitable to all students assigned to that facility. Violation

of this policy may result in referral to the Professional Conduct and Ethics Committee and

termination of the affiliation agreement with the College.

Clinical Supervision

While ICO expects our students in training to be competent in examination procedures and have a

high level of knowledge and skill in diagnosis and treatment plan formation, they are not licensed

practitioners. Therefore, they may not independently examine, diagnose or treat patients. They

should be supervised by an appropriately licensed professional at all times. Student clinicians should

certainly be asked to recommend treatment plans to the doctor, but the final determination of a

patient’s care is in the hands of the licensed practitioner.

The Centers for Medicare and Medicaid Services (CMS ) have rules for the supervision of

students from any profession. Students may conduct all aspects of an examination, but licensed

doctors must either directly observe or re-perform and re-document the history of present illness, all

procedures that contribute to the billable portions of the examination and the medical decision

making, diagnosis and treatment plan. CMS does permit students to conduct the review of systems

history independently. Please find more information at http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/gdelinesteachgresfctsht.pdf

or see Medicare Carrier Manual 15016. These rules apply to Medicare and Medicaid examinations.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/gdelinesteachgresfctsht.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/gdelinesteachgresfctsht.pdf

Please consult with other third party payors about their rules. Government settings or similar should

consult their institutional policy.

Family Educational Rights and Privacy Act (FERPA)

Due to your affiliation with the College as an externship preceptor or adjunct faculty member, if you

applied for and received adjunct status, you are required to follow the rules and regulations of the

Family Educational Rights and Privacy Act that ICO is bound to follow. This means that you may

not divulge any information about the student’s academic and/ or clinical performance to anyone,

including the student’s parents and/ or family members, without the student’s written permission.

The FERPA rules apply to students after graduation as well. Thus, if a student asks you to be a

reference while seeking a job opportunity after graduation, please be sure that they give you

written permission to do so. You may go to the FERPA website if you need further

information. It is http://ferpa.aacrao.org. Please share this information with your colleagues

and office personnel.

http://ferpa.aacrao.org/

ILLINOIS COLLEGE OF OPTOMETRY

ACADEMIC CALENDAR

EXTERNAL CLINIC ROTATIONS

Externs are to follow holiday/vacation schedules as stipulated by each individual external site unless specified within the

calendar. Therefore externs do not necessarily follow the same clinic schedule as the College. For those vacation periods and

NBEO testing dates listed on the calendar, externs will be excused from their off-campus assignments. Other absences must be

approved through the Department of Community Based Education at the College after consultation with the site preceptor. These

days should be made up during available clinic times or during the travel/make up weeks before and after each quarter. Academic

leave for presentations at National meetings (AAO, SECO, etc.) may be excused or made up at the preceptor’s discretion (that time

would be allowed off without make-up if the student was on-campus during that quarter). If the extern is taking additional NBEO

examinations besides those listed, these clinic times should be made-up as any other. When foreseeable, students should

arrange for absences and make-ups by contacting their site preceptor at least six weeks prior to the needed time off. The

College should be notified in ALL cases through the Request for Leave Form.

Please note the quarter break week on the calendar allowed for travel time between sites and to process the students for each

quarter as “in good standing” status. You will receive a copy of the externship calendar for the academic year prior to the start of the

summer quarter.

Explanation of Case Types:

1. Refractive Cases These cases involve patients presenting with potentially several conditions but in which the patient’s refractive condition plays the major role in the assessment and management of the patient. This also includes office visits for follow-up on routine cases where the patient deferred their DFE until another visit and no problems were noted upon patient return.

2. Ocular Disease Oriented Cases These cases involve patients presenting with potentially several conditions but in which the patient’s ocular disease condition plays the major role in assessment and management of the patient. This also includes office visits for follow-up of conditions which may not have been problematic at initial presentation but which are followed to determine the course of the condition (ie. Retinal holes, PVD, mild hypertensive and diabetic retinal changes).

3. Contact Lens Cases These cases involve those patients who present for contact lenses whether as part of their general examination or as a separate contact lens fitting. This also involves the dispensing and follow-up of contact lens patients as well as those cases where contact lenses play a major role in the assessment and management of the patient’s ocular condition (ie. Contact lens related problems).

4. Low Vision Cases These cases involve those patients who present with low vision needs whether as part of their general examination or as a separate low vision examination, including counseling and referral to more extensive rehabilitation services as well as the dispensing and follow-up of low vision devices.

5. Binocular Vision Cases These cases involve those patients who present with binocular vision disorders whether as part of their general examination or as a separate binocular vision assessment. This also involves vision therapy visits and follow-up of home vision therapy treatments as well as those cases where the binocular vision component plays a major role in the assessment and management of the patient’s refractive condition (ie. Asymptomatic patients and monitoring binocular vision status).

6. Pediatric Cases These cases involve patients below the age of 12 with routine refractive and/or ocular disease oriented conditions.

7. Pathology Consultation Cases These cases involve those in which the patient presents for either specific pre-operative testing or immediate (within generally three months) post-operative care or those patients referred to an eye-care specialist for an ocular disease condition.

8. Screenings These cases involve patients who are seen only on a screening only basis or for a specific test in which the assessment and management of the patient was addressed at a separate visit. Examples include visual field testing for another clinician’s assessment and management; fluorescein angiography; photography or actual community screenings. In this last case it would be acceptable to note numbers only, stating “15 community screening patients” without noting all demographics.

9. Observation only These cases involve patients who are seen by another clinician (student or attending) with you in an observation or recording type role. It is acceptable with these patients, not to have complete demographics (eg. You may state “20 patients seen in minor surgery clinic”, etc.).





COMMUNITY-BASED EDUCATION PROGRAM APPLICATION DATA SHEET

(Please Print)

Name of ICO student referring this site: _____________________Box #__________

1. Date form completed:________________ Completed by:_______________________

2. Name of your facility:____________________________________________________

3. Complete mailing address: ____________________________________

____________________________________

____________________________________

____________________________________

4. Eye clinic phone: _____________________ Eye clinic fax: _____________________

5. Web site: ___________________________ Is internet access available for students?___

6. Name of optometrist ICO should contact regarding details of your student program.

Name: ____________________E-mail: ____________________Phone: _____________

7. Name of student contact (if different from above):

Name: ____________________E-mail: ____________________Phone: _____________

8. Names of your full-time attending optometric staff:

Name _________________________ Practice emphasis: _________________________




9. Names of your part-time attending optometric staff:




Application datasheet information – please complete and return

10. From the list below, select the category best describing the overall type of experience your

facility provides (you may circle more than one – see Site Criteria Document for rotation

explanations).

A. Primary Care Rotation

B. Contact Lens Rotation

C. Low Vision Rotation

D. Pediatrics/Binocular Vision Rotation

E. Multi-disciplinary Care (OD/MD) Rotation

Routine refractive cases comprise what percent of student encounters? _____%

Ocular disease cases comprise what percent of student encounters? _____%

Pediatrics/BV cases comprise what percent of student encounters? _____%

Low vision cases comprise what percent of student encounters? _____%

Contact lens cases comprise what percent of student encounters? _____%

Please list any other comments which will help explain the student clinical experience.

11. What is the approximate number of patients that each student would see? ____/week

How many of these patients comprise a full or follow-up examination? ____/week

How many of these patients comprise observations only? ____/week

How many consist of special testing only, e.g., visual fields, etc? ____/week

12. Please describe all of the activities that the student will participate in while at your facility,

e.g., time that will be spent with examinations, special testing (visual fields, etc), clinical

rounds (cornea, glaucoma, etc), journal club, case discussions, observation of surgery.

13. Indicate directions to your facility from a major highway near your facility.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

14. Where should the student park at your facility? Is there a fee?

15. Will the student need his or her own car while assigned to your facility?


16. What meal services are available for the student? If applicable, what is the approximate

cost?

17. If you are outside the Chicago area:

Is housing provided for the student? ___________________

What is the cost of housing? _________________________

If not provided, would your facility be able to consider a housing stipend? _______

If so, how much? ______(Please feel free to call our offices concerning this)

Is the student responsible for locating his or her housing? _____________________

If the student is responsible for locating his or her own housing, what is the approximate cost

on a monthly basis? _____________________________

How far is housing from your facility? __________________

Comments:

18. If housing is provided for the student, please describe.

What major items will the student need to bring?

________________________ ________________________

________________________ ________________________

________________________ ________________________

________________________ ________________________

________________________ ________________________

________________________ ________________________

________________________ ________________________

Comments:

19. What are the hours of your clinic? During what hours should the student be at the clinic? If

this is variable, please explain.

Clinic Hours Student should be at clinic

M: M:

T: T:

W: W:

Th: Th:

F: F:

S: S:


20. What equipment should the student bring to your facility?

________________________ ________________________

________________________ ________________________

________________________ ________________________

________________________ ________________________

________________________ ________________________

________________________ ________________________

21. Please provide a detailed description of your clinic, i.e., number of full exam lanes, special

testing rooms (what type), offices, surgical/laser rooms, etc.

22. What is the maximum number of ICO optometry students your facility can accommodate at a

time?

23. Please list all optometry schools from which you currently accept externs. Do you have a

primary affiliation with one of these schools for the assignment of externs?

24. Do you have optometric residents at your facility? What is the training designation for each

of your residency positions, e.g., Primary Care, Primary Care/Ocular Disease, Low vision,

Contact lens, or Binocular vision?

Resident 1 (name)_________________________ Position Type:____________________



25. What optometry school is your residency program affiliated with?

26. Describe the arrival procedure for the student on his or her first day assigned to your facility.

Please indicate exactly where the student should go, whom should be contacted, and in what

order.


27. What types of interdisciplinary experience does the students get at your facility? Do they

rotate through other medical services? Where? How often?

28. What ophthalmological services are provided at your facility? Is ophthalmology present full

time or part-time. Do you share space directly with ophthalmology?

29. Please list the names of all ophthalmologists who will precept or interact with the students.

What is their specialty?

Name: __________________________ Specialty: ____________________________

Name: __________________________ Specialty: ____________________________

Name: __________________________ Specialty: ____________________________

Name: __________________________ Specialty: ____________________________

Name: __________________________ Specialty: ____________________________

30. What are the demographics of your patient population? Please give an estimate for the

following:

Age range:____________________

Average age:__________________

Percent male:__________________%

Percent female:_________________%

Racial percentages:__________________%

__________________%

__________________%

__________________%

__________________%

31. Do you want the extern to contact you personally by phone or e-mail prior to his/her rotation?

When? Will you contact the student by mailing, etc? Do you have orientation information

that you would like for ICO to distribute to the student prior to the rotation? Other

comments?

32. Please provide three learning objectives for your practice. In other words, What new clinical

skills or knowledge would the student gain from attending your practice? The objectives

only need to be two to three sentences each.

THANK YOU! Please fax or mail to Dr. Brian Caden

Assistant Dean for Community Based Education

Illinois College of Optometry

3241 S. Michigan Ave

Chicago, IL 60616

Fax: 312-949-7749


EXTERNSHIP APPLICATION CHECK LIST

CV’s of all doctors who will be precepting

Copy of current license to practice from all doctors

Representatives signature on MOU

Copy of diploma from accredited school/college of

optometry, medical school or osteopathy school/college

Copy of residency training certificate(if applicable)

MEMORANDUM OF UNDERSTANDING

THIS MEMORANDUM OF UNDERSTANDING (“Memorandum”) is made, entered

into and effective this ____ day of _____________, ______ by and between Illinois College of

Optometry (hereinafter referred to as “School”), an Illinois not-for-profit corporation, and

________________________ (hereinafter referred to as “Site”) to establish the terms and

conditions of a clinical externship program (hereinafter referred to as the “Program”).

ARTICLE I

SITE RESPONSIBILITIES

1.1 Facilities, Equipment and Supplies. Site shall provide the facilities,

equipment and supplies that are customary for clinical instruction at Site.

1.2 Coordinating Personnel. Site shall designate a representative of its facility to

coordinate Program activities in conjunction with School’s designated Program representative.

This coordination shall involve the assignment of Students to specific clinical cases and

experiences, which include conferences, clinics, and Site’s in-service education programs. Sites

shall designate and notify School of the name and credentials of the person responsible for

coordination of the Program at Site and shall notify School of any change in this designation.

1.3 Student Orientation. Site shall provide an orientation to Students

regarding its physical facilities and program regulations, rules, policies, procedures, standards,

schedules, and practices. In addition, Site shall provide School with a copy of the regulations

governing the Students’ Program activities.

1.4 Student Supervision. Site shall exercise appropriate supervision of students who

are assigned to engage in patient care activities at its facility. The supervising OD, MD or DO

must be in good standing with his/her state licensing board and must maintain appropriate

clinical privileges within the facility, as applicable.

1.5 Student Progress and Conduct. Site shall provide reasonable and timely

performance evaluations of Students as outlined in the approved curriculum and Program

objectives provided by School. Moreover, Site shall advise School of any Student whose

achievement, progress, adjustment, health or behavior does not warrant continuation in the

Program.

1.6 Supervisor Licensure. The supervising OD, MD or DO must practice within the

scope of licensure of the state in which Site is located.

1.7 Professional Liability Insurance. Site or the supervising OD, MD or DO shall

provide coverage for its activities in connection with this Memorandum by maintaining

professional liability insurance of no less than one million dollars ($1,000,000) per occurrence

and aggregate limits of three million dollars ($3,000,000). Upon request, Site shall provide proof

of said coverage to School. Site or the supervising OD, MD or DO agree to notify School within

five (5) business days of its receipt of notice that said coverage is to be substantially changed or

cancelled. It should be expressly understood that the coverage required under Section 1.7 shall

in no way limit Sites liability.

1.8 Indemnification. Site shall defend, indemnify and hold harmless School and its

officers, directors, faculty members, employees, residents, Students and authorized agents from

and against any and all claims, losses, damage expenses (including court costs and reasonable

attorney’s fees), judgments and other costs and expenses related to, caused by or proceeding

from the acts, omissions or negligence of the attending doctors, residents, employees and

authorized agents at the Site. School shall provide thirty(30) days notice to Site of any claim

made against it on its obligations under the Memorandum.

1.9 Intent to Discharge Student. Site may, after written notification to School’s

externship office, discharge any Student from his/her assignment if Student’s behavior or state of

health is deemed detrimental to the welfare of patients and /or Site staff.

1.10 School’s Right to Remove Student. Site acknowledges School’s right, either by

written or telephone notification, to immediately remove any Student from Site’s facility for the

following reasons: personal safety issues, allegations of sexual harassment, verbal and/or

physical abuse and failure to comply with School’s educational goals. School’s educational

goals are: direct involvement of Student assigned in patient care, including examination,

treatment and management decisions, consultation with secondary and tertiary providers when

deemed applicable, observation of office surgical procedures, if applicable, and follow-up care.

Student/s are not to be used for technical work nor are they to be involved in performing duties

of office staff.

1.11 Emergency Care of Student. Site shall provided necessary emergency care to

Students participating in the Program. Site is not obligated to administer non-emergency

medical or surgical care to Students participating in the Program.

1.12 Exposure to Infectious Diseases. Site shall notify School of any Student

exposure to infectious diseases, and shall treat Students who are exposed in accordance with Site

policies.

1.13 Site Facility Visitation/Inspection. Site shall permit, upon reasonable request, a

designated School representative or accreditation agency to visit and inspect the facilities that are

utilized for Student training purposes.

ARTICLE II

SCHOOL RESPONSIBILITIES

2.1 Curriculum. School shall design and develop the Program’s clinical educational

curriculum. School shall provide Site with a curriculum description and objectives to be

accomplished by the Program’s end.

2.2 Coordinating Personnel. In accordance with Section 1.2, School shall designate

a Program representative to coordinate Program activities in conjunction with Site’s designated

facility representative.

2.3 Student Prerequisites. School shall schedule for the Program only fourth-year

Students who are in academic good standing as determined by School.

2.4 Student Adherence to Site Requirements. School acknowledges that while at

Site, Students are expected to adhere to Site’s policies, procedures, standards, schedules and

practices. School agrees that it, upon notification by Site’s designated representative, shall

remove any Student who is not adhering to Site’s policies, procedures, standards, schedules and

practices.

2.5 School’s Right to Remove Student. School reserves the right to immediately

remove any Student from Site’s facility, either by written or telephone notification, for the

following reasons: personal safety issues, allegations of sexual harassment, verbal and/or

physical abuse and failure to comply with School’s educational goals. School’s educational

goals are: direct involvement of Student assigned in patient care, including examination,

treatment and management decisions, consultation with secondary and tertiary providers when

deemed applicable, observation of office surgical procedures, if applicable, and follow-up care.

Student/s are not to be used for technical work nor are they to be involved in performing duties

of office staff.

2.6 Professional Liability Insurance. School shall provide coverage for its activities

in connection with this Memorandum by maintaining professional liability insurance of no less

than one million dollars ($1,000,000) per occurrence and aggregate limits of three million dollars

($3,000,000). Upon request, School shall provide proof of said coverage to Site. School agrees

to notify Site within five(5) business days of its receipt of notice that said coverage is to be

substantially changed or cancelled.

2.7 Indemnification. School shall defend, indemnify and hold harmless Site and its

attending doctors, residents, employees and authorized agents from and against any and all

claims, losses, damage expenses (including court costs and reasonable attorney’s fees),

judgments and other costs and expense related to, caused by or proceeding from the acts,

omissions of the officers, directors, faculty members, employees, residents, Students and

authorized agents at School. Site shall provide thirty (30) days notice to School of any claim

made against it on its obligations under this Memorandum.

2.8 Proof of Certifications. Upon request, School shall provide to Site proof of

Students’ Health Insurance Portability and Accountability Act of 1966 (“HIPAA”) and/or

Cardiopulmonary Resuscitation (“CPR”) certifications.

2.9 Proof of Vaccinations. Upon request, School shall provide proof of Students’

health-related vaccinations on record with School.

2.10 Faculty Status. Upon completion of the Adjunct Faculty Application and

approval by the Dean/Vice President for Academic Affairs, School shall provide faculty status to

those individuals involved with direct supervision of Students assigned to Site under this

Program.

ARTICLE III

AUTHORIZED DEPARTMENTAL PROTOCOLS

Both School and Site acknowledge that clinical experiences may vary and as such, both

parties agree that School departments may develop protocols with their clinical Site counterparts

to formalize the Program’s operational details.

ARTICLE IV

TERM AND TERMINATION

This agreement shall be effective on a continuous basis unless terminated in writing by

either party upon ninety(90) days advance notice of a desire to terminate the Memorandum. The

termination notice required by this Article IV shall be sent by certified registered mail. In

addition, this Memorandum may be amended from time to time upon mutual written agreement

between the School and Site.

ARTICLE V

INDEPENDENT CONTRACTOR

Under this Memorandum, both School and Site acknowledge that they are independent

contractors. This Memorandum in no way establishes a partnership, joint venture or similar

relationship between the two parties and should not be construed as such. Nothing in this

memorandum should be interpreted as authorizing one party to act as an agent for the other

party. Each party is liable for its own debts, obligations and acts and omissions, including

payment of all required withholding, social security and other tax benefits. Students are not Site

employees and shall not have the right to claim compensation, insurance or other benefits.

ARTICLE VI

CONFIDENTIALITY

School shall require Students to maintain the confidentiality of patient health information

learned as a result of Students’ clinical experience as mandated by HIPAA and the corresponding

Standards for Privacy of Individually Identifiable Health Information and Security Standards

regulations. No copies or reproductions of patient information in any form, including but not

limited to paper and/or electronic records, shall be made or maintained by Students without prior

authorization of Site. No Student or supervising faculty member shall name patients in papers,

reports or case studies without first acquiring permission from the patient and Site, following

Site policies and procedures for patient confidentially.

ARTICLE VII

ASSIGNMENT AND SUBCONTRACTING

Either party may assign or transfer this Memorandum only with the express written

approval of the other party.

ARTILE VIII

MISCELLANEOUS

3.1 Compliance. School and Site agree that the contents of this Memorandum in no

way require School to refer or admit patients to, or order any goods or services from, Site.

Furthermore, neither School nor Site shall exchange money or payment in any form, other than

gifts of nominal value. In this regard, both parties acknowledge and agree to uphold each party’s

commitment to comply with all federal and state laws and regulations.

3.2 Merger Clause. This Memorandum represents the entire understanding between

School and Site regarding the subject matter of the Memorandum, and supersedes any and all

prior understandings, agreements and memoranda, both oral and written, relating hereto.

3.3 Counterparts. This Agreement may be executed in any number of counterparts,

each of which shall be deemed an original, but all such counterparts together shall constitute one

and the same instrument.

I WITNESS WHEREOF, each party’s authorized representative has executed this

Memorandum of Understanding effective as of the date written on page one of this document.

SCHOOL SITE

Illinois College of Optometry, _______________________________,

An Illinois not-for-profit corporation _______________________________

______________________________, _______________________________,

Date : ________________________ Date:__________________________

By: Stephanie Messner, O.D. By: _____________________________

Its: Dean/Vice President Its: ____________________________

for Academic Affairs

Documents

ILLINOIS COLLEGE OF OPTOMETRY · Primary eye care practices are defined as practices where students interact with practitioners who provide, at least in part, full-scope optometry