RECORD OF SPECIAL EXAMINATION
REGISTRAR’S OFFICE
Instructions: The grade on this examination will be either a P (Pass) grade or a Letter Grade and will be
included in the maximum number of P grade credits that may apply toward graduation. Special Examination
Courses will not satisfy any University Residency Requirements. Credits earned by challenge exam cannot be
used toward a graduate degree or to meet the minimum University course requirement. University credit is
awarded for examinations in courses not already taken by the student.
The fee charged is $40 per course plus an additional fee, determined by the department, of $_________.
To facilitate the checking and approval of special examinations, please fill out this form and secure the
signatures in the listed order.
Please Print or Type
Student I.D. Number Name (Last, First, M.I.)
Course that Special Examination Satisfies
Department Course Number Course Title Credit Hours
Special Examination Certification
________________________________________________________________ _________________________________
Student Signature Date
I certify that I have not taken a college course in this subject, but have received my training in the following manner:
_______________________________________________________________________________________________________________________________
_ _
_______________________________________________________________________________________________________________________
Approvals
NOTE: The examination should not be given until payment of fees has been indicated by the Cashier’s Office.
________________________________________________________________ _________________________________
Advisor Signature Date
________________________________________________________________ _________________________________
Department Head/Dean Signature Date
This student has passed the examination for the above course with the grade of _________.
________________________________________________________________ _________________________________
Instructor Signature Date
Form Submission Instructions
Please Note: This Form contains a grade and therefore must not be given to the student when completed.
Form must be mailed to USU Registrar, 1600 Old Main Hill, Logan, UT 84322-1600, and the mailing envelope’s seal should be
signed across by the instructor.
06/27/2003
