SUPPLEMENTAL FORM FOR ADMISSION

Instructions
Thank you for your interest in the Rosenberg School of Optometry at the University of the Incarnate Word (UIWRSO). UIWRSO offers a program leading to the Doctor of Optometry (O.D.) degree. The School selects students based on the candidate’s application content, pre-professional academic performance, scores from the Optometry Admission Test (OAT), and letters of recommendation, personal statement, and interview.
Please read the following information and fill out the form completely.
·  UIWRSO participates in the Optometry Centralized Application Service (OptomCAS). Applicants must submit all application materials (with the exception of official OAT scores) through OptomCAS to be considered for admission. Applications will be accepted beginning July 1st, 2014. The deadline for submitting an OptomCAS application is May 1st, 2015. Given offers of acceptance are made on a rolling basis, we strongly encourage applicants to apply early.
·  In addition to the OptomCAS application, UIWRSO applicants are required to complete and submit the Supplemental Form for Admission. There is no fee for completing the supplemental form, and the deadline for submitting this form is May 15th, 2015.
·  After completing the electronic Supplemental Form for Admission with electronic signature:
1.  Save an electronic copy of your completed form with YOUR NAME in the title.
Example: UIWRSOSupplementalForm_SallieSmith
It is imperative that your name be attached to the electronic application as shown in the example above, prior to uploading it, in order for us to identify it as your application. Without your name attached to the file, it is likely that your online form may not be processed.
2.  Email your form to: Attn: Admissions
·  It is your responsibility to inform the UIWRSO Office of Admissions of any changes in address or telephone number. Questions pertaining to the application process may be directed to the Rosenberg School of Optometry Office of Admissions at (210) 883-1190.
Personal Information
Ms.Mrs.MissMr.Dr.
Last Name / First Name / Middle Name / Title
Current Address:
(Street) / (City) / (State) / (Zip)
Primary
E-mail Address: / Secondary
E-mail Address:
Current Telephone: /
( ) - /
Cell Phone: /
( ) -
Area Code / Number / Area Code / Number
DOB mm/dd/yyyy: / / / / Last four digits of Social Security #:
How did you hear about us?: / Website / Recruiting Event / Friend or Relative / College Advisor
Social Media / Optometrist / Other:______

PREREQUISITE WORKSHEET: COURSE WORK CREDIT must be listed and computed on a SEMESTER BASIS. Please remember to list all courses which you are currently enrolled or those you plan to complete prior to matriculation with an ‘IP’ for course grade.

TABLE 1 * The third course listed in each group is only applicable to students under the quarter system (3quarters = 2 semesters)
Date Completed
MM/YYYY / Course or Lab # / Title / College or University attended / Semester
Credits / Course Grade / Lab Grade / Repeat Courses
“R”
Biology‡ 1st Sem. or Qtr.
Biology‡ 2nd Sem. or Qtr.
Biology‡* 3rd Qtr.
Biology lab (if graded separately) 1st Sem. or Qtr.
Biology lab (if graded separately) 2nd Sem. or Qtr.
Biology lab* (if graded separately) 3rd Qtr.
Inorganic Chemistry 1st Sem. or Qtr.
Inorganic Chemistry 2nd Sem. or Qtr.
Inorganic Chemistry* 3rd Qtr.
Inorg Chem lab (if graded separately) 1st Sem. or Qtr.
Inorg Chem lab (if graded separately) 2nd Sem. or Qtr.
Inorg Chem lab* (if graded separately) 3rd Qtr.
General Physics 1st Sem. or Qtr.
General Physics 2nd Sem. or Qtr.
General Physics* 3rd Qtr.
Physics lab (if graded separately) 1st Sem. or Qtr.
Physics lab (if graded separately) 2nd Sem. or Qtr.
Physics lab* (if graded separately) 3rd Qtr.
Organic Chemistry
Organic Chemistry lab (if graded separately)
Microbiology or Bacteriology
Microbiology or Bacteriology lab (if graded separately)
Calculus
Calculus* 2nd Qtr.
Biochemistry or Molecular Biology
Statistics
Psychology
English 1st Sem. or Qtr.
English 2nd Sem. or Qtr.
English* 3rd Qtr.

‡ 2 semesters of Biology with lab –OR– 1 semester of Biology with lab and 1 semester of any of the following with lab: Cell Biology, Physiology, Anatomy, or Genetics.

Additional prerequisite courses, for those applying without a Bachelor’s degree.

Course
No. / Prerequisite / Course Title / College or University attended / Date Completed
MM/YYYY / Date to be completed
MM/YYYY
Humanities course 1st S/Q
Humanities course 2nd S/Q
Humanities course* 3rd Q
Behav / Soc. Sci. course 1st S/Q
Behav / Soc. Sci. course 2nd S/Q
Behav/Soc Sci. course* 3rd Q

Humanities course examples: Theology, Philosophy, History, Foreign Language, Literature, Art.

Behavioral & Social Sciences course examples: Sociology, Psych., Polit. Sci., History, Anthropology, Geography, Economics, and Communications.

Academic Information
Please list all optometry schools to which you have applied or intend to apply for Fall 2015:
Optometry School
Please provide a brief comment as to why you believe the optometry program at UIWRSO is a good fit for you: (1000 character limit)

Provide any additional information that may assist the Admissions Committee in evaluating your application: (800 character limit)

Will you have a bachelor’s degree by the time you expect to enter optometry school? / Yes / No
Have you matriculated into/attended any doctorate program in the health professions, for example, optometry or medicine? / Yes / No
If yes, list the name of the optometry school, the dates attended, and explain your reasons for not completing the program. (attach additional sheet if necessary.)
Association of Schools and Colleges of Optometry (ASCO)
Functional Guidelines for Didactic & Clinical Optometric Education
To provide guidance to those considering optometry as a profession, ASCO has established functional guidelines for optometric education. The ability to meet these guidelines, along with other criteria established by individual optometric institutions, is necessary for graduation from an optometric professional degree program.
One of the missions of each school and college of optometry is to produce graduates fully qualified to provide quality comprehensive eye care services to the public. To fulfill this mission, each institution must ensure that students demonstrate satisfactory knowledge and skill in the provision of optometric care. Admission committees, therefore, consider a candidate’s capacity to function effectively in the academic and clinical environments, as well as a candidate’s academic qualifications and personal attributes.
The functional guidelines in optometric education require that the candidate/student possess appropriate abilities in the following areas: 1) observation; 2) communication; 3) sensory and motor coordination; 4) intellectual – conceptual, integrative and quantitative abilities; and 5) behavioral and social attributes.
In any case where a student’s abilities in one of these areas are compromised, he or she must demonstrate alternative means and/or abilities to meet the functional requirements. It is expected that seeking and using such alternative means and/or abilities shall be the responsibility of the student. Upon receipt of appropriate documentation, the school or college will be expected to provide reasonable assistance and accommodation to the student.
The following provides a brief explanation of each area. A more detailed description of each section can be found on the ASCO website.
1.  Observation Abilities: The student must be able to acquire a defined level of required knowledge as presented through lectures, laboratories, demonstrations, patient interaction and self-study. Acquiring this body of information necessitates the functional use of visual, auditory and somatic sensation enhanced by the functional use of other sensory modalities.
2.  Communication Abilities: The student must be able to communicate effectively, efficiently and sensitively with patients and their families, peers, staff, instructors and other members of the health care team. The student must be able to demonstrate established communication skills using traditional and alternative means.
3.  Sensory and Coordination Abilities: Students must possess the sensory and motor skills necessary to perform an eye examination, including emergency care. In general, this requires sufficient exteroception sense (touch, pain, temperature), proprioceptive sense (position, pressure, movement, stereognosis, and vibratory) and fine motor function (significant coordination and manual dexterity using arms, wrists, hands and fingers).
4.  Intellectual-Conceptual, Integrative and Quantitative Abilities: Problem solving, a most critical skill, is essential for optometric students and must be per-formed quickly, especially in emergency situations. In order to be an effective problem solver, the student must be able to accurately and efficiently utilize such abilities as measurement, calculation, reasoning, analysis, judgment, investigation, memory, numerical recognition and synthesis.
5.  Behavioral and Social Attributes: The student must possess the necessary behavioral and social attributes for the study and practice of optometry.
By checking here, you are confirming that you have reviewed and understand the ASCO Functional Standards for Didactic and Clinical Optometric Training.


Disclosure Statement:
Have you ever been convicted in any state or country of a criminal offense, other than a minor traffic violation, where you have been found guilty by a judge or jury or entered a plea of nolo contendere (no contest) or plea bargain; any juvenile offenses; any offenses where the records have been expunged; or any conviction that the applicant is currently appealing, regardless of adjudication?
Please note that background checks are required throughout the UIWRSO program. Failing a background check, depending on severity of offense, may jeopardize patient care privileges and the ability to successfully complete the program. Successful completion of a background check is also required for state licensure within Texas.
Yes / No
If the answer is yes, please explain.

Notice of Nondiscrimination

It is the policy of the University of the Incarnate Word Rosenberg School of Optometry not to engage in any discrimination against an individual because of race, color, religion, gender, national or ethnic origin, non-disqualifying disability, or age, and to comply with all federal and state nondiscrimination and equal opportunity laws and regulations.

Acknowledgment Statement

I certify that the information submitted is complete and true to the best of my knowledge. I certify that I can meet the technical standards listed above, and I authorize release of medical information as it pertains to the substantiation of my health record.

I understand that withholding information, or giving false information, will invalidate my application and will make me ineligible for admission, or subject to dismissal if already enrolled. I consent to and authorize the release of information from all institutions/employers/agencies as it relates to my application process at the Rosenberg School of Optometry. I understand that this form becomes the property of UIWRSO and is not returnable. If accepted, I agree to comply with the rules and regulations of the University of the Incarnate Word Rosenberg School of Optometry while I am a student.

Typed Signature of Applicant: / Date: