Application for Certified Ophthalmic Executive (COE)* Program Credit

Organizations and programs other than ASOA may submit an application to have their course/program approved for ASOA Category A COE credits by the National Board for the Certification of Ophthalmic Executives (NBCOE). These programs must be ophthalmic specific management courses/programs or technical and medical courses. Courses related to clinical patient care taught by industry device manufacturers or pharmaceutical companies are NOT eligible for COE credit.

Section 1: Sponsoring Organization

Organization Name

Address

City

State

Zip

Contact

Title

Phone

xxx-xxx-xxxx

Email *

Section 2: Program for which you are requesting COE credit

Program Title

Program Date

MM/DD/YYYY

Location

Learning Objectives

Section 3: Course Outline

Please attach a list of all courses including course times, presenters, and description of each course.

Attachment

Section 4: Credits for which you are applying

Please check all that apply and enter the number of corresponding COE credits in each category

Category A: Ophthalmic specific management programs/courses, as well as technical and medical courses. Courses related to clinical patient care taught by industry device manufacturers or pharmaceutical companies are not eligible for COE credit. All Category A activities yield a 1:1 credit ratio of hours spent-to-hours earned.

Number of Category A Credits

Category B

Category B: General management/college courses. All Category B activities yield a 1:1 credit ratio of hours spent-to-hours earned.

Number of Category B Credits

Category C

Category C: Miscellaneous. Activities must be within the 6 COE content areas (general ophthalmic knowledge, financial management, operations, information technology management, human resources, risk management & regulatory compliance). Category C activities yield different credit ratios of hours spent-to-hours earned based upon the activity.

Number of Category C Credits

Section 5: Attestation

I hereby certify the information provided on this application is complete and accurate to the best of my knowledge. I understand I may not advertise the program as carrying COE credits until approval is received from ASOA. If approved by ASOA for COE credits, specific language for marketing purposes will be provided by ASOA and must appear in all promotional/course materials which refer to COE credits.

Name

Sponsoring Organization

Signature

Date

MM/DD/YYYY

* The Certified Ophthalmic Executive (COE) credential is the property of the American Society of Ophthalmic Administrators (ASOA) and is administered by the National Board for the Certification of Ophthalmic Executives (NBCOE).