132 Memorial Library • Mankato, MN 56001
507-389-2825 (Phone) • 800-627-3529 (MRS/TTY) • 507-389-1199 (Fax)
CONFIDENTIAL ALTERNATIVE TEST AGREEMENT FORM Semester:_________
SECTION 1: STUDENT SECTION: Students, please complete all of the information in this first
section and the contract on the back side only and return form to Accessibility Resources in ML 132.
Today’s Date ______________________
Name ______________________________ Local Phone _________________ Tech ID_________________
Course Dept. _________Number________Section _______Title______________________________________
Example: BIOL 101 01 General Biology
Instructor’s full name: _______________________________Lab Exams_____Yes Online exams ______ Yes
Example: Prof. Jane Doe ______No _______ No
*PLEASE REMEMBER TO TURN FORM OVER AND READ THE TESTING CONTRACT. I have read the testing
contract and will abide by the Alternative Testing procedures which have been explained to me.
SECTION 2: Accessibility Resources STAFF SECTION - Office Use Only:
This student qualifies for alternative testing because of a documented disability. Accommodations
approved through Accessibility Resources:
________Reduced distraction room
________Extended Time ______X 1.5 ______X 2 (please calibrate extension for all online quizzes/exams)
________Test Scribe ________Test Reader _________Word Processing
_________Calculator ________Private Room
Other (please specify)_______________________________________________________________________
Accessibility Resources Signature: _____________________________Date:___________________
___ Check Acc. Plan _____Email Online Instructors ___ Staff Signature ___ Enter in Database ___ Original sent to Instructor _____Copy & File in 3-ring binder
SECTION 3: INSTRUCTOR’S SECTION
This student is eligible to use the above testing accommodations based on a documented disability. Please read the
information below, sign and return this form promptly to Accessibility Resources (ML 132). Any questions regarding the
accommodation should be directed to the Accessibility Resources Director or Assistant Director at 507-389-2825.
1. It is the course instructor’s responsibility to communicate the test accommodations to any teaching assistant or lab
instructor affiliated with this course to ensure accommodations are provided in all testing/assessment environments.
2. Tests are administered M-F between 7:30am-4:30 pm in the Accessibility Resources testing rooms, ML 132.
3. The course instructor will receive an e-mail 3 days prior to the test date from email@example.com. An Exam
Proctoring Conditions Form will be attached to the email and should be completed and returned with each exam.
4. Test Delivery: Completed exams will be delivered to the department office during the academic year and can be
picked up between the hours of 7:30 AM and 4:00 PM, Monday through Friday during summer session.
5. It is the course instructor’s responsibility to maintain confidentiality with student disability status.
Instructor’s Signature: ___________________________________Date_________________
Please sign and return to Accessibility Resources (Memorial Library 132)
Failure to return a signed agreement does not negate the requirement to provide the test accommodation. (6/20/17 JAS)