Fillable DISABILITY SERVICES TEST ADMINISTRATION REQUEST FORM Instructor Course (Columbus State Community College)

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DISABILITY SERVICES TEST ADMINISTRATION REQUEST FORM Instructor Course (Columbus State Community College)

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DISABILITY SERVICES TEST ADMINISTRATION REQUEST FORM
EMAIL ALL TESTING MATERIALS TO DISABILITY SERVICES TWO BUSINESS DAYS PRIOR TO ADMINISTRATION
Eibling Hall 101 | disability@cscc.edu | 614-287-5089
Instructor
Name:
Last
First
Contact:
Email
Cell phone
Work phone
Department:
Campus Address:
Course
Current
Semester:
Au Sp Su
Incomplete
From:
(Previous semester)
(ex. CSCI 1101)
Course Synonym:
(5-digit #)
Format:
Classroom Blended Distance Learning
Exam Information
Student Name (Please Print)
Date Taken
DS Staff
RM #
Time
Start:
End:
Exam Name:
(ex.Test 3, Quiz 2)
Available Date: Deadline Date: Extended To:
Time Allowed (in class): 2X Time:
Hour(s)
Minutes
Minutes
Student’s Testing Location:
Columbus Delaware Dublin
Hour(s)
Reynoldsburg Out of City
Instructor Permitted Materials:
Book(s) - List Specifically in Special Instructions
Calculator
Type:
Dictionary/Thesaurus
Notes
# of pages:
Note Card(s)
# and size:
Formulas
# of pages:
Other:
NO MATERIALS ALLOWED
Answer format:
Write answers on exam
Answer sheet provided by instructor
Flash drive provided by instructor
Essay booklet provided by DS
Scantron provided by DS 50q 100q
Online Assessment
(ex. SNAP)
Blackboard exam (Paper copy MUST be provided)
Password:
*
Office Use: T R
Special Instructions/Comments
Test Return Instructions: Mailroom Delivery
Pick Up - Disability Services
Pick Up - Student's Testing Location
Office Use
Received
Drop off Email IOM DS Print
Date: DS Initials:
DS Sent to:
AQ DC DB RB OOC
DS Initials:
Returned
Interoffice Mail Faculty Pick Up
Date:
Picked Up By:
DS Accommodations Provided:
2X Time Audio/Electronic Braille/Large Print Calculator CCTV Frequent Breaks Keyboard
Private Room Scribe Scribe for Scantron Spell Check Access Other:
Updated 06/18/18 MM
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DISABILITY SERVICES TEST ADMINISTRATION REQUEST FORM Instructor Course (Columbus State Community College)

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Completed 26 July 2020

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