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Exam Proctoring Request Form (DSS)
For the instructor to complete.

Instructor Name
First Name	Last Name

Email

Student Name
First Name	Last Name

Course Information
Course Title	Course I.D.

Course Number

Exam Information
Exam Date Ex. 01/01/07	Exam Time Ex. 9:00am

Exam Location	Exam Title

Exam Type

In accordance with students contract with DSS they should receive the following accomodations*

Regular Class Time hr(s)	Extended Test Time Allowed for Student hr(s)

Will the Student Require a Distraction Reduced Environment? Yes No

In what format will the test be provided? Paper Disk Online

(Professor to provide test in modified testing format. For assistance please contact the coordinator of DSS )

Paper
Enlarged Print Double Spaced Scanned for Kurzweil 3000 Reader Needed

Diskette
Software Needed Ms Word Kurzweil 3000 Other


Audio Tape
Audio Tape Other

Questions regarding DSS contracts and accomodationsshould be directed to Laura Lyndon, Director of Disability Support Services. Ext. 1658 lyndon@hnu.edu

In what format should the student submit his/her completed test?
Diskette Audio Tape Handwritten Response Printed from MS Word or other computer software Other

Materials Allowed
Calculator
Notes
Book
Spellchecker
Other Materials

Other Accomodations Requested
Physical Assistance
Flexibility with Movement During Test
Magnification Equipment
Ergonomic Solutions
Other Accomodations

Please use the space below for testing directions or any additional comments.


Instructors must bring a copy of the exam with test directions to Brennan 57B or email the exam with directions to coleman@hnu.edu. The completed exam can be retrieved by the instructor from Brennan 57B. If you have any other questions please call the Student Success Center ext. 1356. Forms must be submitted 48 hours prior to the desired test date. All late or incomplete froms will not be processed and the exam will not be administered.