It is the student's responsibility to take this form to the instructor two weeks before the test to discuss testing arrangements. Allow enough advance time for the accommodations to be arranged.
|Student’s Name||Today's Date|
|Requested Testing Date||Time (Include extended time if applicable)|
_____ Instructor will leave test with the Campus Service Center (First Floor Peralta MOB)
_____ Student will pick up test from instructor.
_____ Instructor will email test to firstname.lastname@example.org
RETURN / PICKUP
_____ Student will submit test to the Campus Service Center (3100 Telegraph Avenue) for the instructor to pick up.
_____ Student will return the test in a sealed envelope to instructor.
ANY SPECIAL INSTRUCTIONS:
|Instructor Signature | phone||Student Signature | phone|
Must be submitted to Assistant to the Dean one (1) week in advance.
|_____ Computer (Specify program: ________________________________ )|
|_____ Extended time (Specify: ________ )|
|_____ Test taped|
|_____ Screen Reader|