IAR Spring 2021
For Internal Use Only:
Sequence: 00002
Pick Batch: 2669240 Delivery: 28504878 Order/Line: 4542479/2 Page 1 of 3
Deliver To: SA0990000
SAMPLE SCHOOL
99 SAMPLE STREET
SAMPLE BLDG.
SAMPLE CITY, USA 99999
SAMPLE PERSON
Phone: (999) 9999999
Fax: (111) 1111111
School Chain-of-Custody Form
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 followi
ng list contains the security numbers of all secure test materials (such as Test Booklets, Answer Documents, Human Reader Scripts, etc.) that are
included in this shipment to your school. Use this checklist to track the secure materials while in your school.
Do not return this form with your test materials. Check your state policy for specific requirements for how long to maintain this document. You will need it to refer to if
an investigation of missing materials takes place. Any material listed on this document must be returned to Pearson, and the school and LEA/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 equival
ent form. For further information, see Section 3.3.2 of the TCM.
BEFORE TESTING
Each Test Administrator must sign this form and indicate the date and time when materials are issued. If a consecutive range of materials is taken, then sign and
mark the date/time next to the security number for the first document and the last document, and then draw an arrow between the two signatures and date/time.
AFTER TESTING
The School Test Coordinator must sign this form and indicate the date and time when materials are returned (immediately upon test completion). If a consecutive range
of materials is taken, then sign and mark the date/time next to the security number for the first document and the last document, and then draw an arrow between the two
signatures
