TEST ANSWER SHEET
(Sponsor name)
DATE (MM/DD/YYYY):
__________________________
PROTOCOL NUMBER:
__________________________
NAME: ________________________________________________
LOCS III
________________________
(Name of test)
___MD ___OD___DO___PHD
EMAIL:___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Please note: The NO/NC scales extend from 0.1 through 6.9 and the C/P scales extend from 0.1 through 5.9.
IMAGE #
NO
NC
LOCS III CLASSES
C
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
P
Alt-P
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
I hereby acknowledge that I have taken this test without anyone assisting me and without any written assistance of any kind. I
acknowledge and agree that this test answer sheet represents my own efforts and only my own efforts. I will not provide my own test
answers to anyone for the purposes of assisting his or her efforts to complete a test and I will keep this completed test sheet
confidential.
Signed _______________________________________________
Date: ______________________________
Tests will not be processed unless the above is signed and dated. Please fax the completed answer sheet to
1-413-825-0244. Tests may also be scanned and sent as attachments to jenn@chylackinc.com