Elizabeth City State University
Distance Education
Request to use a Proctor
To address the testing needs of the growing number of students that are participating in Distance Learning (DL) courses, the
Distance Education department will allow on campus sessions to be locally proctored.
Exam proctors should be a faculty member, administrator, or other professional staff member of a school or college, an
employee of a commercial testing center, a library staff member or your supervisor at work. Your proctor cannot be a family
member or a co-worker. Request for an individual proctor must be approved by your course instructor. Your instructor
reserves the right to contact your requested proctor.
The proctor must provide access to an appropriate testing environment which includes a computer with internet access, fax
machine, and telephone. Proctors are required to monitor the exam until it is completed by the student. Students and
proctors are not permitted to leave the testing area until the test has been completed. Proctors MUST ask to see and verify
photo ID (Driver's License).
*** INSTRUCTIONS FOR STUDENTS: (1) Place cursor on the line and type (2) use tab key to advance to next
section. It is the student's responsibility to complete the form and fax or email it to their instructor at least five
business days prior to the exam. ***
Student Information
Student Name: ___________________________ Phone #: ___________________ Date:___________
Email Address: _________________________________________________________________
Course Name: _______________________________________________________________________________
Course Number: ________________________________________________________________________________
Instructor Information
Instructor Name: _________________________ Phone # ________________ Fax #:_______________
Email Address: _________________________________________________________________
Proctor Information
Proctor Name:___________________________ Phone #:_______________ Fax #: ______________
Email Address: ______________________________________________________
Proctor’s Occupation: _________________________________________________
Exam Information
Type of exam: Midterm Final Other
Location of exam: ________________________________ Date of exam: ________________________
Time of exam: ___________________
*** INSTRUCTIONS FOR FACULTY: It is the faculty members responsibility to complete the form and fax or
email it to the proctor at least two business days prior to the exam. ***
Students may may not use books, internet resources, or notes during exam.
Password Protected: Yes No If yes provide password: __________________
Location of Exam (within Blackboard):___________________________________________________________________
Maximum Duration for exam: __________ Exam must be completed by: (date and time) _________________________
