Fillable IAR Spring 2021 District Chain-of-Custody Form for Initial (Illinois Assessment of Readiness)

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IAR Spring 2021 District Chain-of-Custody Form for Initial (Illinois Assessment of Readiness)

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The IAR Spring 2021 District Chain-of-Custody Form for Initial (Illinois Assessment of Readiness) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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For Internal Use Only:
Page 1 of 2
Pick Batch: 2669240 Delivery: 28504878 Order/Line: 4542479/1 Sequence: 00001
IAR Spring 2021
District Chain-of-Custody Form for
Initial Shipment of Materials
Deliver To: SA0990000
SAMPLE SCHOOL DISTRICT
99 SAMPLE STREET
SAMPLE BLDG.
SAMPLE CITY, USA 99999
SAMPLE PERSON
Phone: (999) 9999999
Fax: (111) 1111111
Ship To: SA0990000
SAMPLE SCHOOL DISTRICT
99 SAMPLE STREET
SAMPLE BLDG.
SAMPLE CITY, USA 99999
SAMPLE PERSON
Phone: (999) 9999999
Fax: (111) 1111111
INSTRUCTIONS:
The following list contains the range of all secure materials that are included in this shipment.
Do not return this form with your test materials. Check your state policy for specific requirements for how long to retain this
document. You will need it if an investigation of missing materials takes place. The school and district will be held responsible for
any secure materials that were received at the school but not returned.
All secure documents must be tracked using this form or an equivalent form. For further information, see Section 3.3.2 of the TCM.
The School Test Coordinator and the District Test Coordinator must be careful about checking the barcode
sequence of the materials to make sure the sequence of materials received and returned matches what is on the form.
School
Number
Deliver To Form Security
Number
From
Security
Number To
Qty Qty
Sent Rec'd
STC
Initial &
Date/ Time
IAR Spring 2021
For Internal Use Only:
Page 2 of 2
Pick Batch: 2669240 Delivery: 28504878 Order/Line: 4542479/1 Sequence: 00001
District Chain-of-Custody Form for Initial Shipment
of Materials
Deliver To:
SA0990000
SAMPLE SCHOOL DISTRICT
Ship To:
SA0990000
SAMPLE SCHOOL DISTRICT
School
Number
Deliver To Form Security
Number
From
Security
Number To
Qty Qty
Sent Rec'd
STC
Initial &
Date/ Time
I certify that the receipt of all test materials from Pearson has been verified by:
- Counting the test materials,
- Verifying the rang
e of the test materials security numbers, and
- Verifying that the test material count and the range of security numbe
rs are consistent with the information provided on
this form.
(Print) DTC/STC First Name, Last Name, and Title Telephone Number
DTC/STC Signature Date
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IAR Spring 2021 District Chain-of-Custody Form for Initial (Illinois Assessment of Readiness)

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Completed 23 April 2021

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