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 | Date |
| ________________________________ | ________________________________ |
| Instructor | Course |
| ________________________________ | ________________________________ |
| Requested Testing Date | Time (Include extended time if applicable) |
PICK-UP - in a sealed envelope on _______________ (Date and Time):_____ Instructor will leave test at front desk.
_____ Instructor will leave test with Diane Hansen, Coordinator of Academic Support and Disabled Student Services.
_____ Student will pick up test from instructor.
RETURN - Student will submit test in a sealed envelope:_____ to front desk for instructor's mailbox.
_____ to Diane Hansen, Coordinator of Academic Support and Disabled Student Services.
_____ to instructor.
| ________________________________ | ________________________________ |
| Instructor Signature | phone | Student Signature | phone |
STUDENT ACCOMMODATIONS
Must be submitted to Assistant to the Dean one (1) week in advance.
| _____ Computer (Specify software: ________________________________ ) | |
| _____ Extended time (Specify: ________ ) | _____ Test taped |
| _____ Student Tutor to read test | _____ Proctor |
| _____ Writer | _____ Interpreter |
| _____ Writer | _____ Use of standard dictionary |
