Disability Services Proctored Exam Form

Instructor, please complete the following form for students receiving testing accommodations and attach the exam and any other instructions. Please be thorough with the information provided.
Student Name*
Date Exam will be taken*
MM slash DD slash YYYY
Time Exam will be taken*

: Hours

Minutes

AM/PM
Instructor Name*
First Last
Course*
Instructor Email*
Instructor Contact Number (Required)*
Campus*
Time Allowed*

(PLEASE put time allowed in hours and minutes. This must be a specific time limit, not “unlimited” or “double time”)
Instructor Special Instructions:
- Use of Calculator
- Use of Notes
- Use of Books
- Other (Specify):
If you selected Other, you must specify:
Date Exam was taken (For Proctor to Record)
MM slash DD slash YYYY
Due to Website changes, attachments must be emailed to the testing center. You will receive an email once you submit this form. The email must be forwarded to the testing center with the exam attached.

Due to Website changes, attachments must be emailed to the testing center. You will receive an email once you submit this form. The email must be forwarded to the testing center with the exam attached.