Travel to Teach Reporting Form

Travel to Teach Training Report

SEE is required by law to track the quantities and types of services provided.

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AR Code

Clinic Overview

Clinic Location / Facility Name

Host Ophthalmologist / Team Lead

Program Start Date

Program End Date

Training Narrative

Please describe the training activities that took place during your program, including subject matter covered, format, and duration.

Please share any notable or memorable stories from your trip.

Development Goals

Please describe any plans for continued engagement with the training program. This may include virtual follow-up sessions, ongoing communication with students, or scheduling another Travel to Teach program in the future

Information of Eye Care Professionals Trained

Do you have your individual trainee information in excel format already?(Required)

Yes

No, I'd like to enter them manually

If you have more than 30 trainees please put your trainee information into excel formatting.

Please upload your trainee information file here:

Accepted file types: csv, xlsx, Max. file size: 50 MB.

Please include trainee first name, last name, email, training category, gender, and summary of training.

Trainee #1

Name

First Last

Category

Gender

Trainee 1: Summary of Training

Trainee 1: "Other" Category

Trainee #2

Name

First Last

Category

Gender

Trainee 2: Summary of Training

Trainee 2: "Other" Category

Trainee #3

Name

First Last

Category

Gender

Trainee 3: Summary of Training

Trainee 3: "Other" Category

Trainee #4

Name

First Last

Category

Gender

Trainee 4: Summary of Training

Trainee 4: "Other" Category

Trainee #5

Name

First Last

Category

Gender

Trainee 5: Summary of Training

Trainee 5: "Other" Category

Trainee #6

Name

First Last

Category

Gender

Trainee 6: Summary of Training

Trainee 6: "Other" Category

Trainee #7

Name

First Last

Category

Gender

Trainee 7: Summary of Training

Trainee 7: "Other" Category

Trainee #8

Name

First Last

Category

Gender

Trainee 8: Summary of Training

Trainee 8: "Other" Category

Trainee #9

Name

First Last

Category

Gender

Trainee 9: Summary of Training

Trainee 9: "Other" Category

Trainee #10

Name

First Last

Category

Gender

Trainee 10: Summary of Training

Trainee 10: "Other" Category

Trainee #11

Name

First Last

Category

Gender

Trainee 11: Summary of Training

Trainee 11: "Other" Category

Trainee #12

Name

First Last

Category

Gender

Trainee 12: Summary of Training

Trainee 12: "Other" Category

Trainee #13

Name

First Last

Category

Gender

Trainee 13: Summary of Training

Trainee 13: "Other" Category

Trainee #14

Name

First Last

Category

Gender

Trainee 14: Summary of Training

Trainee 14: "Other" Category

Trainee #15

Name

First Last

Category

Gender

Trainee 15: Summary of Training

Trainee 15: "Other" Category

Trainee #16

Name

First Last

Category

Gender

Trainee 16: Summary of Training

Trainee 16: "Other" Category

Trainee #17

Name

First Last

Category

Gender

Trainee 17: Summary of Training

Trainee 17: "Other" Category

Trainee #18

Name

First Last

Category

Gender

Trainee 18: Summary of Training

Trainee 18: "Other" Category

Trainee #19

Name

First Last

Category

Gender

Trainee 19: Summary of Training

Trainee 19: "Other" Category

Trainee #20

Name

First Last

Category

Gender

Trainee 20: Summary of Training

Trainee 20: "Other" Category

Trainee #21

Name

First Last

Category

Gender

Trainee 21: Summary of Training

Trainee 21: "Other" Category

Trainee #22

Name

First Last

Category

Gender

Trainee 22: Summary of Training

Trainee 22: "Other" Category

Trainee #23

Name

First Last

Category

Gender

Trainee 23: Summary of Training

Trainee 23: "Other" Category

Trainee #24

Name

First Last

Category

Gender

Trainee 24: Summary of Training

Trainee 24: "Other" Category

Trainee #25

Name

First Last

Category

Gender

Trainee 25: Summary of Training

Trainee 25: "Other" Category

Trainee #26

Name

First Last

Category

Gender

Trainee 26: Summary of Training

Trainee 26: "Other" Category

Trainee #27

Name

First Last

Category

Gender

Trainee 27: Summary of Training

Trainee 27: "Other" Category

Trainee #28

Name

First Last

Category

Gender

Trainee 28: Summary of Training

Trainee 28: "Other" Category

Trainee #29

Name

First Last

Category

Gender

Trainee 29: Summary of Training

Trainee 29: "Other" Category

Trainee #30

Name

First Last

Category

Gender

Trainee 30: Summary of Training

Trainee 30: "Other" Category

Total Participants by Category

Board-Certified Ophthalmologists

Ophthalmology Residents

Ophthalmology Fellows

Optometrists

Nurses

Technicians

Opticians

Medical Students

Other

Other Trainee Category

Total Overall Trainees

Travel to Teach Training Report

Clinic Overview

Training Narrative

Development Goals

Information of Eye Care Professionals Trained

Trainee #1

Trainee #2

Trainee #3

Trainee #4

Trainee #5

Trainee #6

Trainee #7

Trainee #8

Trainee #9

Trainee #10

Trainee #11

Trainee #12

Trainee #13

Trainee #14

Trainee #15

Trainee #16

Trainee #17

Trainee #18

Trainee #19

Trainee #20

Trainee #21

Trainee #22

Trainee #23

Trainee #24

Trainee #25

Trainee #26

Trainee #27

Trainee #28

Trainee #29

Trainee #30

Total Participants by Category

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