EXAM PROCTOR FORM
To be completed by instructor and student and returned to the ARC
three days prior
to taking accommodated exams.
University Testing • 970-943-7056 • Taylor Hall Suite 302
For Office Use Only Notes:
Start Proctor Initials
Finish Proctor Initials
Date
TEST INFORMATION
To be completed by the student
Student Name
Student ID # Course:
Instructor Name
Scheduled Class Time
TEST DELIVERY
All fields MUST be completed by the instructor
Instructor Drop-off Email (disability@western.edu)
TEST DATE & TIME
The student will take the exam on:
Date Time a.m. p.m.
EXAM TYPE
Paper Based
Computer Based Administered via Access password:
ALLOWED TESTING TOOLS
Notes Calculator Ruler Dictionary Translator Software Extra Time
3x5 Index Card Spell Checker Textbook Formula Sheet
Other:
Standard time given for this exam:
Instructor Approval Signature
METHOD OF RETURN
Instructor Pickup in Taylor Hall 302 Email:
ACCOMMODATIONS
To be completed by Disability Services.
Extended Time: Reduced Distraction
Other:
RETURN TO INSTRUCTOR
Instructor Pickup Email Date Returned: Time Returned:
Pickup Signature
click to sign
signature
click to edit
click to sign
signature
click to edit
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