Fillable Date of Birth: mm/dd/yyyy Phone#: (xxx)xxx-xxxx (Western Technical College)

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Date of Birth: mm/dd/yyyy Phone#: (xxx)xxx-xxxx (Western Technical College)

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Student Last Name:
Student First Name:
M.I.:
Student ID#:
Date of Birth: mm/dd/yyyy
Email:
Phone#: (xxx)xxx-xxxx
Street Address:
City:
State
Program Enrolled:
Course Title:
Course #:
Assessor Name:
Payment Information
A stamp marked “Paid” must be shown on this form or a receipt attached/scanned must be included to verify payment was
made. Assessment Fee: $50 = Challenge Exam; $90 = Portfolio/Demonstration
$50 = Challenge Exam $90 = Portfolio/Demonstration $0 = Fee Waiver (if applicable)
Course Enrollment
Currently Enrolled in Course?
Yes
No
If yes, upon successful completion, do you want the Registrar's Office to withdraw
you from the course? (Refunds are given in accordance to the State Uniform Fee Refund
Policy.)
Yes No
Student Signature Date:
-------- Below this Line - Assessor Use Only --------
Credit for Prior Learning
Please indicate the types of assessment used to evaluate course competencies, check all that apply. If the student was unsuccessful
in a competency(s), please provide feedback.
Course Competency 1
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 2
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 3
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 4
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 5
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Credit for Prior Learning
Form
Course Competency 6
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 7
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 8
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 9
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 10
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 11
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 12
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 13
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 14
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Course Competency 15
(if applicable)
Written/Portfolio
Demonstration/Performance/Oral
Successful
Unsuccessful
Challenge Exam ONLY
Passing Score Needed: Passing Score Earned:
Feedback
Final Assessment
Student successfully met course competencies/passed Challenge Exam
Student unsuccessfully met course competencies/did not pass Challenge Exam
Assessor Signature: Date:
Adult Learning Specialist Signature: Date
A
ttn Assessor:
Please submit form and students graded work, and return either electronically or through interoffice mail to:
Tracy Noyes, R164E | noyest@westerntc.edu | 608-785-9441
CPL Reporting Code: 2F 2J 2M 3J 4J 4M 5J 5M 6J
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Date of Birth: mmddyyyy Phone: (xxx)xxx-xxxx (Western Technical College)

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Completed 27 July 2020

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