EBAA Accreditation Inspection Application Step 1 of 7 0% Review the Instructions BelowComplete this application to begin the process for inspection and accreditation by EBAA. See the EBAA’s Accreditation Policies and Procedures, Medical Standards, and Constitution and Bylaws for more information about EBAA inspections and accreditation policies and procedures. This application should be completed for any establishment that performs any eye banking function and is seeking EBAA accreditation (e.g. comprehensive and limited function eye banks). To learn more about how the EBAA Accreditation Board defines these eye banking functions, visit Accreditation Governance and Functions. All fields are required, unless about satellite or separate entities that are not applicable to the applying eye bank. By clicking the "Save and Continue Later" button at the bottom of the page, you will be able to start the form and finish it later. You will receive an email with instructions on how to go back to the form. An application will not be considered complete and inspector(s) will not be assigned until all information is provided to the satisfaction of the EBAA Accreditation Board Chair(s). Additional documentation may be required upon review of your application. If you have questions about this application or the required supporting documentation, please contact Jennifer DeMatteo at 202-775-4999, ext.117 or via email at jennifer@restoresight.org.Person Completing ApplicationEnter the information for the person completing this application.Name of ContactName of Contact First Last Designation Contact Job TitleContact Job Title Contact Email AddressContact Email Address Eye Bank Applying for InspectionEnter the information for the eye bank applying for inspection.Organization NameOrganization Name Organization AddressOrganization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Organization Phone NumberOrganization Phone Number Parent OrganizationIf applicable, complete the fields below. Otherwise, skip to the Medical Director section.Parent Organization NameParent Organization Name Parent Organization AddressParent Organization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Medical DirectorMedical Director NameMedical Director Name First Last Designation Is the Medical Director an ophthalmologist?Is the Medical Director an ophthalmologist? Yes No Has the Medical Director completed a corneal fellowship?Has the Medical Director completed a corneal fellowship? Yes No If yes, list the Fellowship location and year completed.If yes, list the Fellowship location and year completed. If no, do you have documentation of a consulting relationship with an ophthalmologist who has completed a corneal fellowship?If no, do you have documentation of a consulting relationship with an ophthalmologist who has completed a corneal fellowship? Yes No Consulting Ophthalmologist’s NameConsulting Ophthalmologist’s Name Consulting Ophthalmologist’s Fellowship Location and Year CompletedConsulting Ophthalmologist’s Fellowship Location and Year Completed Does the Medical Director fulfill the role of an EBAA CEBT in a supervisory and training position?Does the Medical Director fulfill the role of an EBAA CEBT in a supervisory and training position? Yes No If yes, year of initial CEBT CertificationIf yes, year of initial CEBT Certification Year of last recertificationYear of last recertification FileIf you have any supplemental documentation or CVs related to your Medical Director, upload them here. Drop files here or Select files Accepted file types: jpg, pdf, png, doc, Max. file size: 50 MB. Back-up Medical DirectorBack-up Medical Director NameBack-up Medical Director Name First Last Designation Is the Back-up Medical Director an ophthalmologist?Is the Back-up Medical Director an ophthalmologist? Yes No Has the Back-up Medical Director completed a corneal fellowship?Has the Back-up Medical Director completed a corneal fellowship? Yes No If yes, list the Fellowship location and year completed.If yes, list the Fellowship location and year completed. If no, do you have documentation of a consulting relationship with an ophthalmologist who has completed a corneal fellowship?If no, do you have documentation of a consulting relationship with an ophthalmologist who has completed a corneal fellowship? Yes No Consulting Ophthalmologist’s NameConsulting Ophthalmologist’s Name Consulting Ophthalmologist’s Fellowship Location and Year CompletedConsulting Ophthalmologist’s Fellowship Location and Year Completed Certified Eye Bank TechnicianDoes your bank employ at least one EBAA Certified Eye Bank Technician?Does your bank employ at least one EBAA Certified Eye Bank Technician? Yes No If yes, list the CEBT Name.If yes, list the CEBT Name. Year of initial CEBT CertificationYear of initial CEBT Certification Year of last recertificationYear of last recertification If no, list the consulting CEBT name.If no, list the consulting CEBT name. Consulting CEBT OrganizationConsulting CEBT Organization Is the organization EBAA accredited?Is the organization EBAA accredited? Yes No Executive DirectorExecutive DirectorExecutive Director First Last Designation Executive Director Email AddressExecutive Director Email Address Executive Director Phone NumberExecutive Director Phone Number Is the Executive Director also a CEBT?Is the Executive Director also a CEBT? Yes No Year of initial CEBT CertificationYear of initial CEBT Certification Year of last recertificationYear of last recertification Eye Bank OperationsAre cleaning and maintenance records, equipment certifications, and monitoring charts available for review at the main location applying for site inspection?Are cleaning and maintenance records, equipment certifications, and monitoring charts available for review at the main location applying for site inspection? Yes No Does your bank have donor records readily available for review including recipient follow-up information and adverse reaction files since your last EBAA inspection?Does your bank have donor records readily available for review including recipient follow-up information and adverse reaction files since your last EBAA inspection? Yes No Does the eye bank have sufficient whole eyes / corneoscleral discs to demonstrate practical recovery or processing techniques as outlined in the Accreditation Policy & Procedures? *If No, the Applying Eye Bank must make arrangements to acquire adequate tissue for the day of inspection.Does the eye bank have sufficient whole eyes / corneoscleral discs to demonstrate practical recovery or processing techniques as outlined in the Accreditation Policy & Procedures? *If No, the Applying Eye Bank must make arrangements to acquire adequate tissue for the day of inspection. Yes No Does the eye bank have a Policy and Procedures Manual ready for submission and review by the Accreditation Board Inspectors?Does the eye bank have a Policy and Procedures Manual ready for submission and review by the Accreditation Board Inspectors? Yes No Have you had a Change in Governance since your last EBAA inspection including a change in the type(s) of Eye Bank Functions this bank performs?Have you had a Change in Governance since your last EBAA inspection including a change in the type(s) of eye banking function this bank performs? Yes No If yes, please describe.If yes, please describe.If yes, was the Change in Governance reported to the EBAA OfficeIf yes, was the Change in Governance reported to the EBAA Office? Yes No Has your facility been inspected by the FDA or Health Canada since your last EBAA inspection?Has your facility been inspected by the FDA or Health Canada since your last EBAA inspection? Yes No If yes, date of inspectionIf yes, date of inspection Was a 483 or any other citation issued?Was a 483 or any other citation issued? Yes No If yes, please describe.If yes, please describe. Did your bank forward all written documentation of observations, findings or results to the EBAA Office?Did your bank forward all written documentation of observations, findings or results to the EBAA Office? Yes No Attach copies of 483s and/or any other observations/documentation that the bank received from the regulatory authority.Attach copies of 483s and/or any other observations/documentation that the bank received from the regulatory authority. Drop files here or Select files Accepted file types: jpg, pdf, png, doc, Max. file size: 50 MB. Has your facility been inspected by any other Official Agencies since your last EBAA Inspection?Has your facility been inspected by any other official agencies since your last EBAA Inspection? Yes No If yes, please provide the name(s) of the Agenc(ies) that inspected your facility and the dates of any inspection(s). Provide the scope of the inspection and it’s findings to this application.If yes, please provide the name(s) of the Agenc(ies) that inspected your facility and the dates of any inspection(s). Provide the scope of the inspection and it’s findings to this application. Did your bank forward all written documentation of observations, findings or results to the EBAA Office and the Chair(s) of the Accreditation Board as required by EBAA?Did your bank forward all written documentation of observations, findings or results to the EBAA Office and the Chair(s) of the Accreditation Board as required by EBAA? Yes No Eye Bank/Entity Proficiency VerificationProficiency VerificationComplete the table below to verify the handling of at least 25 surgical corneas annually for each eye banking function (as defined by EBAA) for which the eye bank/entity is applying for accreditation. Identify at least 25 surgical tissue ID numbers from within the past 12 months, and document every eye banking function that applies to that tissue ID number for which the eye bank/entity is applying for accreditation. To select the appropriate function, place an "X" in the box associated with that function. Multiple functions may be marked for any particular tissue ID. Click the "+" to add additional tissues. Please note, for each function, at least 25 tissues must be marked to be considered for Accreditation for that specific function.Tissue ID#RecoveryProcessingTissue StorageTissue EvaluationDonor Eligibility DeterminationFinal Distribution Proficiency VerificationEnter the total number of tissues listed above that were handled for each function.RecoveryProcessingTissue StorageTissue EvaluationDonor Eligibility DeterminationFinal Distribution Eye Bank Function or Task IdentificationFor each eye bank function / task listed below, identify every entity / location that performs the task for the organization applying for this site inspection.Perform body examination or physical assessment1. Perform body examination or physical assessment Yes No 1 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform a pen light examination2. Perform a pen light examination Yes No 2 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform ocular recoveries (ie. Enucleation/in-situ)3. Perform ocular recoveries (ie. Enucleation/in-situ) Yes No 3 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform laboratory corneoscleral disc excisions4. Perform laboratory corneoscleral disc excisions Yes No 4 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Preserve sclera5. Preserve sclera Yes No 5 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform microkeratome processing (e.g. DSAEK processing)6. Perform microkeratome processing (e.g. DSAEK processing) Yes No 6 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform manual dissection processing (e.g. DMEK processing)7. Perform manual dissection processing (e.g. DMEK processing) Yes No 7 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform laser (e.g. femtosecond) assisted processing8. Perform laser (e.g. femtosecond) assisted processing Yes No 8 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform tissue transfers, scleral trims or blood rinsing9. Perform tissue transfers, scleral trims or blood rinsing Yes No 9 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform Processing other than those listed above in #4-9 (see MS Glossary for definition of Processing)10. Perform processing other than those listed above in #4-9 (see MS Glossary for definition of Processing) Yes No Describe the other processing function.Describe the other processing function. 10 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform plasma dilution calculations11. Perform plasma dilution calculations Yes No 11 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Obtain answers to the donor risk assessment interview12. Obtain answers to the donor risk assessment interview (DRAI) Yes No 12 Entities that perform that taskIf you have a physically separate satellite or contracted establishment (includes OPO or tissue bank) that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments. Name, City and State of Separate SatelliteName of Contracted Establishment Perform slit lamp examination13. Perform slit lamp examination Yes No 13 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Evaluate tissue using a specular microscope14. Evaluate tissue using a specular microscope Yes No 14 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Determine donor eligibility15. Determine donor eligibility Yes No 15 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Evaluate infectious disease testing results16. Evaluate infectious disease testing results Yes No 16 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Store storage solution(s)17. Store storage solution(s) Yes No 17 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Store ocular tissue18. Store ocular tissue Yes No 18 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Maintain refrigerator records19. Maintain refrigerator records Yes No 19 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Maintain cleaning and environmental monitoring records20. Maintain cleaning and environmental monitoring records Yes No 20 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Maintain tissue evaluation records21. Maintain tissue evaluation records Yes No 21 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Store instruments22. Store instruments Yes No 22 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Maintain donor files23. Maintain donor files Yes No 23 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Perform instrument sterilization in-house24. Perform instrument sterilization in-house Yes No 24 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Label tissue for distribution25. Label tissue for distribution Yes No 25 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Provide a unique ISBT 128 Tissue Identifier for each tissue26. Provide a unique ISBT 128 Tissue Identifier for each tissue Yes No 26 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Track tissue27. Track tissue Yes No 27 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Ship tissue released for transplant to surgeons or surgical facilities28. Ship tissue released for transplant to surgeons or surgical facilities Yes No 28 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Maintain complete donor or recipient case records29. Maintain complete donor or recipient case records Yes No 29 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Seek required follow-up information 3-6 months post-op30. Seek required follow-up information 3-6 months post-op Yes No 30 Entities that perform that taskIf you have a physically separate satellite or contracted establishment that performs the above task, enter their information below. Click the "+" to add additional satellites or contracted establishments.Name, City and State of Separate SatelliteName of Contracted Establishment Satellite Locations/Contracted Establishments - Skip and Proceed to Next Page if Not ApplicableIf a Satellite (or Other) Location or a Contracted Establishment was listed as performing a task outlined in the previous section, complete the chart below for each establishment, marking “yes” or “no” as appropriate. (The eye bank applying should not be included as it is addressed elsewhere in this application.)ListEnter yes or no in each column. Click the "+" symbol to add a new row for each Satellite (or other) location.Organization NameDoes the entity have a Medical Director?CEBT on Staff?EBAA Accredited?FDA Registered?CLIA Certified?Joint Commission Accredited?State Inspected? Please include any comments regarding the satellite locations listed above.Please include any comments regarding the satellite locations listed above.Is the applying eye bank/entity (the facility applying for site inspection), a subsidiary or part of another organization?Is the applying eye bank/entity (the facility applying for site inspection), a subsidiary or part of another organization? For example, if this bank is a satellite, “yes” should be checked. Yes No If yes, name of parent organization?If yes, name of parent organization? Executive Director Name of Parent OrganizationExecutive Director Name of Parent Organization Medical Director Name of Parent OrganizationMedical Director Name of Parent Organization Does the applying eye bank/entity (the facility applying for site inspection), own, operate or use any physically separate location(s) for the performance of any eye bank tasks or functions (not including contracted establishments)?Does the applying eye bank/entity (the facility applying for site inspection), own, operate or use any physically separate location(s) for the performance of any eye bank tasks or functions (not including contracted establishments)? Yes No ListList all physically separate locations. Click the "+" button to add rows for additional locations.Location: Name, City, and StateIs this location separately registered with FDA? (Yes or No)Has this location already been included for inspection during a different EBAA Accreditation Cycle? (Yes or No) Separate Location Information - Skip and Proceed to Next Page if Not ApplicableFor each physically separate location, complete the following information. If you do NOT have separate locations, you can skip this page by clicking "Next" at the bottom of the page.Separate Location #11 Name of LocationName of Location 1 Organization AddressOrganization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 1 Location Phone NumberLocation Phone Number 1 NameName of Lead Staff at This Location First Last Designation 1 Lead Staff Job TitleLead Staff Job Title 1 Lead Staff Email AddressLead Staff Email Address 1 Does the location have its own Policy and Procedures Manual?Does the location have its own Policy and Procedures Manual? Yes No 1 If No, what Policy and Procedures Manual does the facility use (Name of Organization)?If No, what Policy and Procedures Manual does the facility use (Name of Organization)? 1 Does the location have a CEBT on staff?Does the location have a CEBT on staff? Yes No 1 If yes, provide CEBT NameIf yes, provide CEBT Name First Last 1 Year of initial certificationYear of initial certification 1 Year of last recertificationYear of last recertification 1 If no, provide consulting CEBT NameIf no, provide consulting CEBT Name First Last 1 Organization NameOrganization Name 1 Is the organization EBAA Accredited?Is the organization EBAA Accredited? Yes No 1 Does the location have, or have access to, a qualified Medical Director or his/her designee?Does the location have, or have access to, a qualified Medical Director or his/her designee? Yes No 1 Is the Medical Director an Ophthalmologist?Is the Medical Director an Ophthalmologist? Yes No 1 Medical Director NameMedical Director Name First Last Designation 1 Medical Director AddressMedical Director Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 1 Medical Director Email AddressMedical Director Email Address 1 How many surgical corneas did this location handle over the past year (January 1 to December 31)?How many surgical corneas did this location handle over the past year (January 1 to December 31)? This includes any of the following: recovered, processed, stored, evaluated, determined donor eligibility, or distributed the ocular tissue. 1 Do you have an additional location to submit information about?Do you have an additional location to submit information about? Yes No Separate Location #22 Name of LocationName of Location 2 Organization AddressOrganization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 2 Location Phone NumberLocation Phone Number 2 NameName of Lead Staff at This Location First Last Designation 2 Lead Staff Job TitleLead Staff Job Title 2 Lead Staff Email AddressLead Staff Email Address 2 Does the location have its own Policy and Procedures Manual?Does the location have its own Policy and Procedures Manual? Yes No 2 If No, what Policy and Procedures Manual does the facility use (Name of Organization)?If No, what Policy and Procedures Manual does the facility use (Name of Organization)? 2 Does the location have a CEBT on staff?Does the location have a CEBT on staff? Yes No 2 If yes, provide CEBT NameIf yes, provide CEBT Name First Last 2 Year of initial certificationYear of initial certification 2 Year of last recertificationYear of last recertification 2 If no, provide consulting CEBT NameIf no, provide consulting CEBT Name First Last 2 Organization NameOrganization Name 2 Is the organization EBAA Accredited?Is the organization EBAA Accredited? Yes No 2 Does the location have, or have access to, a qualified Medical Director or his/her designee?Does the location have, or have access to, a qualified Medical Director or his/her designee? Yes No 2 Is the Medical Director an Ophthalmologist?Is the Medical Director an Ophthalmologist? Yes No 2 Medical Director NameMedical Director Name First Last Designation 2 Medical Director AddressMedical Director Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 2 Medical Director Email AddressMedical Director Email Address 2 How many surgical corneas did this location handle over the past year (January 1 to December 31)?How many surgical corneas did this location handle over the past year (January 1 to December 31)? This includes any of the following: recovered, processed, stored, evaluated, determined donor eligibility, or distributed the ocular tissue. 2 Do you have an additional location to submit information about?Do you have an additional location to submit information about? Yes No Separate Location #33 Name of LocationName of Location 3 Organization AddressOrganization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 3 Location Phone NumberLocation Phone Number 3 NameName of Lead Staff at This Location First Last Designation 3 Lead Staff Job TitleLead Staff Job Title 3 Lead Staff Email AddressLead Staff Email Address 3 Does the location have its own Policy and Procedures Manual?Does the location have its own Policy and Procedures Manual? Yes No 3 If No, what Policy and Procedures Manual does the facility use (Name of Organization)?If No, what Policy and Procedures Manual does the facility use (Name of Organization)? 3 Does the location have a CEBT on staff?Does the location have a CEBT on staff? Yes No 3 If yes, provide CEBT NameIf yes, provide CEBT Name First Last 3 Year of initial certificationYear of initial certification 3 Year of last recertificationYear of last recertification 3 If no, provide consulting CEBT NameIf no, provide consulting CEBT Name First Last 3 Organization NameOrganization Name 3 Is the organization EBAA Accredited?Is the organization EBAA Accredited? Yes No 3 Does the location have, or have access to, a qualified Medical Director or his/her designee?Does the location have, or have access to, a qualified Medical Director or his/her designee? Yes No 3 Is the Medical Director an Ophthalmologist?Is the Medical Director an Ophthalmologist? Yes No 3 Medical Director NameMedical Director Name First Last Designation 3 Medical Director AddressMedical Director Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 3 Medical Director Email AddressMedical Director Email Address 3 How many surgical corneas did this location handle over the past year (January 1 to December 31)?How many surgical corneas did this location handle over the past year (January 1 to December 31)? This includes any of the following: recovered, processed, stored, evaluated, determined donor eligibility, or distributed the ocular tissue. 3 Do you have an additional location to submit information about?Do you have an additional location to submit information about? Yes No Separate Location #44 Name of LocationName of Location 4 Organization AddressOrganization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 4 Location Phone NumberLocation Phone Number 4 NameName of Lead Staff at This Location First Last Designation 4 Lead Staff Job TitleLead Staff Job Title 4 Lead Staff Email AddressLead Staff Email Address 4 Does the location have its own Policy and Procedures Manual?Does the location have its own Policy and Procedures Manual? Yes No 4 If No, what Policy and Procedures Manual does the facility use (Name of Organization)?If No, what Policy and Procedures Manual does the facility use (Name of Organization)? 4 Does the location have a CEBT on staff?Does the location have a CEBT on staff? Yes No 4 If yes, provide CEBT NameIf yes, provide CEBT Name First Last 4 Year of initial certificationYear of initial certification 4 Year of last recertificationYear of last recertification 4 If no, provide consulting CEBT NameIf no, provide consulting CEBT Name First Last 4 Organization NameOrganization Name 4 Is the organization EBAA Accredited?Is the organization EBAA Accredited? Yes No 4 Does the location have, or have access to, a qualified Medical Director or his/her designee?Does the location have, or have access to, a qualified Medical Director or his/her designee? Yes No 4 Is the Medical Director an Ophthalmologist?Is the Medical Director an Ophthalmologist? Yes No 4 Medical Director NameMedical Director Name First Last Designation 4 Medical Director AddressMedical Director Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 4 Medical Director Email AddressMedical Director Email Address 4 How many surgical corneas did this location handle over the past year (January 1 to December 31)?How many surgical corneas did this location handle over the past year (January 1 to December 31)? This includes any of the following: recovered, processed, stored, evaluated, determined donor eligibility, or distributed the ocular tissue. 4 Do you have an additional location to submit information about?Do you have an additional location to submit information about? Yes No Separate Location #55 Name of LocationName of Location 5 Organization AddressOrganization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 5 Location Phone NumberLocation Phone Number 5 NameName of Lead Staff at This Location First Last Designation 5 Lead Staff Job TitleLead Staff Job Title 5 Lead Staff Email AddressLead Staff Email Address 5 Does the location have its own Policy and Procedures Manual?Does the location have its own Policy and Procedures Manual? Yes No 5 If No, what Policy and Procedures Manual does the facility use (Name of Organization)?If No, what Policy and Procedures Manual does the facility use (Name of Organization)? 5 Does the location have a CEBT on staff?Does the location have a CEBT on staff? Yes No 5 If yes, provide CEBT NameIf yes, provide CEBT Name First Last 5 Year of initial certificationYear of initial certification 5 Year of last recertificationYear of last recertification 5If no, provide consulting CEBT NameIf no, provide consulting CEBT Name First Last 5 Organization NameOrganization Name 5 Is the organization EBAA Accredited?Is the organization EBAA Accredited? Yes No 5 Does the location have, or have access to, a qualified Medical Director or his/her designee?Does the location have, or have access to, a qualified Medical Director or his/her designee? Yes No 5 Is the Medical Director an Ophthalmologist?Is the Medical Director an Ophthalmologist? Yes No 5 Medical Director NameMedical Director Name First Last Designation 5 Medical Director AddressMedical Director Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 5 Medical Director Email AddressMedical Director Email Address 5 How many surgical corneas did this location handle over the past year (January 1 to December 31)?How many surgical corneas did this location handle over the past year (January 1 to December 31)? This includes any of the following: recovered, processed, stored, evaluated, determined donor eligibility, or distributed the ocular tissue. 5 Do you have an additional location to submit information about?Do you have an additional location to submit information about? Yes No Separate Location #66 Name of LocationName of Location 6 Organization AddressOrganization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 6 Location Phone NumberLocation Phone Number 6 NameName of Lead Staff at This Location First Last Designation 6 Lead Staff Job TitleLead Staff Job Title 6 Lead Staff Email AddressLead Staff Email Address 6 Does the location have its own Policy and Procedures Manual?Does the location have its own Policy and Procedures Manual? Yes No 6 If No, what Policy and Procedures Manual does the facility use (Name of Organization)?If No, what Policy and Procedures Manual does the facility use (Name of Organization)? 6 Does the location have a CEBT on staff?Does the location have a CEBT on staff? Yes No 6 If yes, provide CEBT NameIf yes, provide CEBT Name First Last 6 Year of initial certificationYear of initial certification 6 Year of last recertificationYear of last recertification 6 If no, provide consulting CEBT NameIf no, provide consulting CEBT Name First Last 6 Organization NameOrganization Name 6 Is the organization EBAA Accredited?Is the organization EBAA Accredited? Yes No 6 Does the location have, or have access to, a qualified Medical Director or his/her designee?Does the location have, or have access to, a qualified Medical Director or his/her designee? Yes No 6 Is the Medical Director an Ophthalmologist?Is the Medical Director an Ophthalmologist? Yes No 6 Medical Director NameMedical Director Name First Last Designation 6 Medical Director AddressMedical Director Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 6 Medical Director Email AddressMedical Director Email Address 6 How many surgical corneas did this location handle over the past year (January 1 to December 31)?How many surgical corneas did this location handle over the past year (January 1 to December 31)? This includes any of the following: recovered, processed, stored, evaluated, determined donor eligibility, or distributed the ocular tissue. 6 Do you have an additional location to submit information about?Do you have an additional location to submit information about? Yes No NotesPlease use this section to provide any additional information you deem important for the Accreditation Board co-chairs to have regarding your inspection.Please upload any additional files or supplemental materials.Please upload any additional files or supplemental materials. Drop files here or Select files Accepted file types: jpg, pdf, png, doc, Max. file size: 50 MB.
