Ctr Exam Eligibility Determination Form
ADVERTISEMENT
1CTR EXAM ELIGIBILITY DETERMINATION FORM
Complete this form in its entirety for a formal review of your eligibility. This form is NOT REQUIRED for eligibility approval.
Unofficial transcripts are acceptable. Allow up to 2 weeks for a response.
Candidate Information
Name:
Today’s Date: Expected Test Date: Telephone #
Email:
____________________________________________________________________________________________________________________________
Candidate Details
Education:
Experience:
(Check all that apply)
60+ college‐level credits
Have you completed the 160‐hour clinical practicum under a CTR’s
NCRA‐accredited Certificate Program: ____________________________
supervision? No Yes
NCRA‐accredited Associate’s Degree Program: _____________________
1950 hours (equivalent to 1 year) in the Cancer Registry field.
Associate’s Degree (specify) ____________________________________
Dates
: ______________________________________________
Bachelors Degree (specify) _____________________________________
Masters Degree (specify) ______________________________________
Other: ______________________________________________________
Other: _____________________________________________________
________________________________________________________________
________________________________________________________________
Specific Coursework:
Skills:
(list course title & completion date)
(Check all that apply)
Human Anatomy: _______________________________________________
Abstracting
Human Physiology: ______________________________________________
Case finding
Medical Terminology: ____________________________________________
Cancer committee/conference
Computer Basics in Healthcare: ____________________________________
Data quality assurance
Follow‐up
________________________________________________________________
Other coursework: ______________________________________________
Reporting
State/NCDB submissions
________________________________________________________________
________________________________________________________________
SUBMIT THIS FORM WITH COPIES OF YOUR TRANSCRIPTS TO:
NCRA STAFF USE ONLY: Eligible: YES NO
Eligible under Route: __________
●
Mail: 1330 Braddock Place Suite 520, Alexandria, VA 22314
Fax: 703‐299‐6620
Eligibility Case #: ____________
●
Questions: Contact NCRA at 703‐299‐6640 x312
Email: ctrexam@ncra‐usa.org
Date Recorded: _______________
Updated 8/31/15
For details of Eligibility Routes, go to
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial