moc.moh.gov.mymoc.moh.gov.my/borang/RPL form for 18(1) LATEST V3.docx · Web viewI hereby declare that all of the information/documents provided to support this application are authentic,

PORTFOLIO FOR RECOGNITION OF PRIOR LEARNINGRegistration under section 18(1)

PART 1 : PERSONAL DETAILS

NAME

IC NUMBER

REFERENCE NUMBER(for MOC use only)

1

Recent photo

PART 2 : DETAILS OF LEARNING ACQUIRED (please list down from the most recent)

A) CERTIFICATED LEARNING

NO. YEAR AWARDED TITLE OF CERTIFICATION

LEVEL OF THE AWARD(CERTIFICATE/DIPLOMA/

DEGREE)AWARDING BODY

1.

2.

3.

4.

5.

2

B) EXPERIENTIAL LEARNING : EMPLOYMENT HISTORY

NO. NAME OF EMPLOYER ADDRESS OF PLACE OF EMPLOYMENT

PERIOD SERVED(MONTH/YEAR)

POSITION HELDFROM TO

1.

2.

3.

4.

5.

6.

7.

8.

3

C) ALL CORE CONTINUING EDUCATION ACTIVITIES ATTENDED (For each continuing education activity attended candidate must attached a full programme and proof of attendance-refer appendix 5)

NO.NAME/TITLE OF TRAINING OR

COURSELOCATION PROVIDER /

ORGANIZER DATELENGTH (Hours/ Days/

Month)

FOR MOC USE ONLYNO OF HOURS COVERED IN EACH AREA

(Please refer Appendix 7)

1 2 3 4 5 6

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

4




Month)



1 2 3 4 5 6

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

5




Month)



1 2 3 4 5 6

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

6

D) LIST OF CLINICAL CASES SEEN THROUGHOUT WORKING LIFE – CLINCAL CASES OF APPLICANTS WILL BE ASSESSED BASED ON THE PROVIDED RUBRIC AS MENTIONED ON PAGE 39

1. CASES OF MYOPIA WITH/WITHOUT ASTIGMATISM

NO. DATE A/G/R* HISTORY TYPES OF TEST USED

EXAMINATION FINDINGSMANAGEMENT

MARKS*(FOR MOC USE

ONLY)RE LE

1. ABCDTotal :

2. ABCDTotal :

3. ABCDTotal :

4. ABCDTotal :

5. ABCDTotal :

*A : Age *G : Gender *R : Race *MARKS : FOR MOC USE ONLY

7




MARKS*(FOR MOC USE

ONLY)RE LE

6. ABCDTotal :

7. ABCDTotal :

8. ABCDTotal :

9. ABCDTotal :

10. ABCDTotal :


1. CASES OF MYOPIA WITH/WITHOUT ASTIGMATISM8



MARKS*(FOR MOC USE

ONLY)RE LE

11. ABCDTotal :

12. ABCDTotal :

13. ABCDTotal :

14. ABCDTotal :

15. ABCDTotal :


9




MARKS*(FOR MOC USE

ONLY)RE LE

16. ABCDTotal :

17. ABCDTotal :

18. ABCDTotal :

19. ABCDTotal :

20. ABCDTotal :


10




MARKS*(FOR MOC USE

ONLY)RE LE

21. ABCDTotal :

22. ABCDTotal :

23. ABCDTotal :

24. ABCDTotal :

25. ABCDTotal :



11



MARKS*(FOR MOC USE

ONLY)RE LE

26. ABCDTotal :

27. ABCDTotal :

28. ABCDTotal :

29. ABCDTotal :

30. ABCDTotal :


1. CASES OF MYOPIA WITH/WITHOUT ASTIGMATISMNO. DATE A/G/R* HISTORY TYPES OF TEST EXAMINATION FINDINGS MANAGEMENT MARKS*

12

USED (FOR MOC USE ONLY)RE LE

31. ABCDTotal :

32. ABCDTotal :

33. ABCDTotal :

34. ABCDTotal :

35. ABCDTotal :



13



MARKS*(FOR MOC USE

ONLY)RE LE

36. ABCDTotal :

37. ABCDTotal :

38. ABCDTotal :

39. ABCDTotal :

40. ABCDTotal :



14


41. ABCDTotal :

42. ABCDTotal :

43. ABCDTotal :

44. ABCDTotal :

45. ABCDTotal :


1. CASES OF MYOPIA WITH/WITHOUT ASTIGMATISM15



MARKS*(FOR MOC USE

ONLY)RE LE

46. ABCDTotal :

47. ABCDTotal :

48. ABCDTotal :

49. ABCDTotal :

50. ABCDTotal :



16


51. ABCDTotal :

52. ABCDTotal :

53. ABCDTotal :

54. ABCDTotal :

55. ABCDTotal :


2. CASES OF HYPEROPIA WITH/WITHOUT ASTIGMATISMNO. DATE A/G/R* HISTORY TYPES OF TEST

USEDEXAMINATION FINDINGS MANAGEMENT MARKS*

(FOR MOC USE RE LE17

ONLY)

1. ABCDTotal :

2. ABCDTotal :

3. ABCDTotal :

4. ABCDTotal :

5. ABCDTotal :


2. CASES OF HYPEROPIA WITH/WITHOUT ASTIGMATISMNO. DATE A/G/R* HISTORY TYPES OF TEST EXAMINATION FINDINGS MANAGEMENT MARKS*

18


6. ABCDTotal :

7. ABCDTotal :

8. ABCDTotal :

9. ABCDTotal :

10. ABCDTotal :


2. CASES OF HYPEROPIA WITH/WITHOUT ASTIGMATISM



MARKS*(FOR MOC USE

ONLY)RE LE

19

11. ABCDTotal :

12. ABCDTotal :

13. ABCDTotal :

14. ABCDTotal :

15. ABCDTotal :





MARKS*(FOR MOC USE

ONLY)RE LE

20

16. ABCDTotal :

17. ABCDTotal :

18. ABCDTotal :

19. ABCDTotal :

20. ABCDTotal :





MARKS*(FOR MOC USE

ONLY)RE LE

21

21. ABCDTotal :

22. ABCDTotal :

23. ABCDTotal :

24. ABCDTotal :

25. ABCDTotal :


22




MARKS*(FOR MOC USE

ONLY)RE LE

26. ABCDTotal :

27. ABCDTotal :

28. ABCDTotal :

29. ABCDTotal :

30. ABCDTotal :


2. CASES OF HYPEROPIA WITH/WITHOUT ASTIGMATISM23



MARKS*(FOR MOC USE

ONLY)RE LE

31. ABCDTotal :

32. ABCDTotal :

33. ABCDTotal :

34. ABCDTotal :

35. ABCDTotal :


3. CASES OF PRESBYOPIA24



MARKS*(FOR MOC USE

ONLY)RE LE

1. ABCDTotal :

2. ABCDTotal :

3. ABCDTotal :

4. ABCDTotal :

5. ABCDTotal :


25

3. CASES OF PRESBYOPIA



MARKS*(FOR MOC USE

ONLY)RE LE

6. ABCDTotal :

7. ABCDTotal :

8. ABCDTotal :

9. ABCDTotal :

10. ABCDTotal :


3. CASES OF PRESBYOPIA26



MARKS*(FOR MOC USE

ONLY)RE LE

11. ABCDTotal :

12. ABCDTotal :

13. ABCDTotal :

14. ABCDTotal :

15. ABCDTotal :


3. CASES OF PRESBYOPIANO. DATE A/G/R* HISTORY TYPES OF TEST EXAMINATION FINDINGS MANAGEMENT MARKS*

27


16. ABCDTotal :

17. ABCDTotal :

18. ABCDTotal :

19. ABCDTotal :

20. ABCDTotal :



28


21. ABCDTotal :

22. ABCDTotal :

23. ABCDTotal :

24. ABCDTotal :

25. ABCDTotal :



29


26. ABCDTotal :

27. ABCDTotal :

28. ABCDTotal :

29. ABCDTotal :

30. ABCDTotal :



30


31. ABCDTotal :

32. ABCDTotal :

33. ABCDTotal :

34. ABCDTotal :

35. ABCDTotal :



31


36. ABCDTotal :

37. ABCDTotal :

38. ABCDTotal :

39. ABCDTotal :

40. ABCDTotal :





MARKS*(FOR MOC USE

ONLY)RE LE

32

41. ABCDTotal :

42. ABCDTotal :

43. ABCDTotal :

44. ABCDTotal :

45. ABCDTotal :


3. CASES OF PRESBYOPIANO. DATE A/G/R* HISTORY TYPES OF TEST

USEDEXAMINATION FINDINGS MANAGEMENT MARKS*

(FOR MOC USE RE LE33

ONLY)

46. ABCDTotal :

47. ABCDTotal :

48. ABCDTotal :

49. ABCDTotal :

50. ABCDTotal :





MARKS*(FOR MOC USE

ONLY)RE LE34

51. ABCDTotal :

52. ABCDTotal :

53. ABCDTotal :

54. ABCDTotal :

55. ABCDTotal :





MARKS*(FOR MOC USE

ONLY)RE LE

35

56. ABCDTotal :

57. ABCDTotal :

58. ABCDTotal :

59. ABCDTotal :

60. ABCDTotal :


4. CASES WITH OCULAR ABNORMALITIES



MARKS*(FOR MOC USE

ONLY)RE LE

36

1. ABCDTotal :

2. ABCDTotal :

3. ABCDTotal :

4. ABCDTotal :

5. ABCDTotal :


4. CASES WITH OCULAR ABNORMALITIES



MARKS*(FOR MOC USE

ONLY)RE LE

37

6. ABCDTotal :

7. ABCDTotal :

8. ABCDTotal :

9. ABCDTotal :

10. ABCDTotal :


Rubrics for CLINICAL CASES SEEN THROUGHOUT WORKING LIFE

Completeness of case (A) Appropriate selection of Description of test result (C) Management (D)

38

tests (B)

0 No case information or critical information missing.

Missing the majority of appropriate tests

Descriptions provided are unclear or incorrect.

Minimal management or are all inappropriate for this case.

1Minimal case information provided. Missing important pieces relevant to case

The tests chosen are broadly appropriate, just missing minimal important tests.

The descriptions contain a mix of accurate and inaccurate information

Contain a mix ofappropriate and inappropriate management or fail to address most issues raised by diagnoses

2Documents most case information, only less important information has been omitted.

The tests chosen are accurate with no more than one error inclusion of appropriate tests.

The descriptions are mostly accurate with only minimal errors.

Management addresses most issues raised by diagnoses

3 Thoroughly documents all pertinent case components

No more than one error of omission or inclusion of appropriate tests.

The descriptions are accurate. Management are appropriate and comprehensive

E) DISPENSING

39

1. FULL FRAME

NO. DATERX LENS* LENS TYPE*

REMARKSRE LE CR39 GLASS SINGLE

VISIONMULTIFOCAL BIFOCAL

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

* Tick (/) for where applicable

40

1. FULL FRAME




16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.


41

1. FULL FRAME




31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.


42

1. FULL FRAME




46.

47.

48.

49.

50.


43

2. SEMI RIMLESS




1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.


44

2. SEMI RIMLESS




16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.


45

2. SEMI RIMLESS




31.

32.

33.

34.

35.

36.

37.

38.

39.

40.


46

3. RIMLESS




1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.


47

3. RIMLESS




16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.


48

3. RIMLESS




31.

32.

33.

34.

35.

36.

37.

38.

39.

40.


F) OTHER RELEVANT LEARNING SKILLS / ACTIVITIES 49

OTHER ACTIVITIESThis may include your hobbies/sports/recreation/ social/community service /training given / consultancy services or other activities which might be relevant to the core competencies required.

YEAR

WHAT I HAVE LEARNT(Please tick which apply)

(Please refer Appendix 6 for list of skills relating to the MQA domains)

1. 2. 3. 4. 5. 6. 7. 8.

1.

2.

3.

4.

G) LANGUAGE SKILLS

LANGUAGE

LEVEL OF COMPETENCE (tick which apply)1: POOR; 2: GOOD; 3: AVERAGE; 4: EXCELLENT

LISTENING READING SPEAKING WRITING

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

1.

2.

3.

50

PART 3 : REFEREES (relevant to work situation)

NAME

POSITION

ORGANISATION

PHONE NUMBER OFFICE:(Compulsory)

MOBILE:

EMAIL ADDRESS

RELATIONSHIP

NAME

POSITION

ORGANISATION

PHONE NUMBER OFFICE:(Compulsory)

MOBILE:

EMAIL ADDRESS

RELATIONSHIP

PART 4 : SELF DECLARATION51

I hereby declare that all of the information/documents provided to support this application are authentic, true and accurate. I fully understand the Terms and Conditions of the application and agree that my application will be rejected if I have falsified any information in any way.

Signature:Name:Date:

This application is subject to Terms and Conditions stated below

a. Documents that are not in English or Bahasa Malaysia must be accompanied by a certified full translation. b. The Management of MOC is authorised by the applicant, to make references to and use the information or data in this application as may be deemed necessary. c. The certification applied for is designed to meet requirements set by the Malaysian Qualifications Agency (MQA) and MOC. Admission to the Accelerated Programme

applied for, using this RPL Certificate is subject to the Academic Regulations approved by the respective Universities / Colleges.

This application form, complete with all certified documents must be sent to MOC.

CHECK LIST

Yes No

Photocopy of IC1 recent passport size photographCertified Certificates/Documents3 copies of application form

For MOC Use OnlyAcknowledgment

Date

52

LIST OF EVIDENCE

Evidence that can be provided for application

Direct Evidence Indirect EvidenceCertificatesYou can provide copies of your qualification

School certificates Statement of results Courses completed at work

Written RecordsYou can provide copies of

Diaries Records Journals Articles

Work samplesYou can provide samples of your work

Drawings or photographs Reports Written materials Projects Objects Work of arts

E-mailYou can provide copies of email communications which verify

Customer feedback Work activities Written skills

Records of workplace activitiesYou can provide documents that verify your work activities

Notes Emails Completed worksheets Workplace agreeement Contracts

Supporting lettersYou can provide letters to verify your claim from

Employers Community group People you have work with (paid and unpaid work)

DocumentsYou can provide evidence that shows what you have done in your life

Media articles Meritoriuos Awards

Appendix 5

List of skills on what I have learned based on 8 Learning Outcomes Domain.

1. Knowledge

2. Practical Skills

3. Social skills and responsibilities

4. Values, attitudes and professionalism

5. Communication, leadership and team skills

6. Problem Solving and scientific skills

7. Information management and lifelong learning skills

8. Managerial and entrepreneurial skills

Appendix 6

List of areas

1. Basic Sciences

2. Optics

3. Ocular Sciences

4. Vision Sciences

5. Clinical Optometry

6. Clinical Practice

Appendix 7