Disability Support Services
Test Accommodations Request Form
CAMPUS: La Plata Prince Frederick Leonardtown Waldorf Hughesville Other: ________________
Student Name: ___________ Date: ___________________
Telephone: Email: _____________________________
Semester: ______ Course Title: __________________________________
Professor: ____________________________________________________________________
Scheduled Date of Quiz/Exam:
Start Time
End Time
Extended Time: Time and a half Double time
Scribe: ______ Proctor: ___________________________
Assistive Technology: Word Q3 __________________ Dragon Kurzweil Other:
This form is to be filled out by students granted accommodations that otherwise require them
to take a test proctored outside of the testing site.
Students must schedule a time to take exams/quizzes at least one week in advance
of exam/quiz date. Submission of this form does not guarantee the exact time/date listed.
Only items approved by the instructor will be allowed in the testing room.
It is the student’s responsibility to remind professors to submit tests to the testing center
prior to the scheduled exam time. Per DSS policy, exams/quizzes can be taken only during
overlapping DSS and testing center hours of operation.
Approval of dates/times will be sent to students via email.
Student Signature: _____________________________ Date:
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