SHSU Services for Students with Disabilities (SSD)
SSD Testing Form
To Be Completed by Instructor and submitted to the SSD Office in person at the Lee Drain
Annex, by Fax 936-294-3794, or by E-Mail:
Link to SSD Testing Procedures:
Student Name: ______________________________________________________________
Course #: ______________ Class Day/Time: _______________ Campus: ___________
Date of Appointment: ___________________ Appointment Time: ________________
Instructor: __________________________________________________________________
Instructor Phone: ____________ Standard Time Allowed for Exam: ____________
Student May Use the following:
___ NO Materials Allowed (other than penc ils, Scantron, or Blue Book)
Special Instructions:
Please return exam by ONE of the following methods
(SSD does not hand-deliver exams):
Graphing Calculat or Open Not es
Soft ware/Websit e
(Please Specify Below)
Scient ific Calculat or
Open Book
Four Function Calculat or
Not e/Formula Card
Handout Provided
Not e/Formula Sheet
Scrat ch Paper
(Provided by proctor)
(Please Specify Below)
Campus Mail (Fill in Mail Box Number)
Instructor Pick-Up
Email (Fill in Address)
Other Pick-Up (Fill in Name)
Fax (Fill in Number)
Sealed Envelope Sent w ith Student (Specify
Bldg. and Room Number)
Instructors Signature: __________________________________________________________________
Below for SSD Office use: Test Scheduled for: ____________________________________
TF Received: __________________________ Test Received: ________________________________________
Test Taken: ___________________________ Proctor/Reader: ______________________________________
Professor Called/Emailed: _______________ Test Returned/Picked Up: ______________________________
Rvsd 02/19/2018
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