CONSENT FORM FOR RESIDENTS TAKING THE

2013 RADIATION ONCOLOGY IN-TRAINING EXAMINATION

(TXITTM)
Institution Name: ____________________________________________________
Site Number: ___ ___ ___ ___

I understand that the purpose of the in-training examination is to provide

information as a resident in radiation oncology to the director of my training
program concerning my graduate medical education. Accordingly, I understand
that this is a condition of my taking this in-training examination and that the
results will be transmitted to my program for that purpose. Scores will only be received
by the director of the training program upon completion of this form.

RESIDENT NAME: ________________________________________________

(Please type or print clearly)

RESIDENT SIGNATURE:____________________________________________

ACR Member ID Number: ___ ___ ___ ___ ___ ___ ___ ___
(Optional)

Completed consent forms can be faxed to: TXIT Coordinator at: (703) 716-1283
or emailed to: intrainingexam@acr.org.