Department of Student Success & Retention
Student Accessibility Center
FACULTY: Please note: If hand-delivering exams, place them inside a sealed envelope, with this sheet
completed, and attached to the outside. If you have any questions, please call SAC at 736.2739 or email
Course: _______________________________ Professor:_______________________________________
Professor’s Phone # ________ Office Location: __________ Email: _______________________________
Scheduled Class Test Date: ___________________ Test Time: __________________
Return test to professor via Campus Mail ( )
Return test to professor via Office ( )
Return scanned Test to professor via e-mail ( )
Student has permission to use the following: IF NONE CHECKED, NONE WILL BE PERMITTED
Open notes ( ) Open books(s) ( ) Calculator/graphing calculator ( )
Other:_____________________________________ NO AIDS MAY BE USED ( )
How much time will the class have to complete this examination? ________________
Time with accommodations: ________________
Student Name
Time Student
Time Student
Test Proctor Signature
Additional Notes from Professor/Department:
[To be signed by student(s) just prior to test administration] Student acknowledgement: “By signing this
form, I accept the responsibility to adhere to Wesley College’s Academic Honesty policy.”
____________________________________________________________________ _______________________________________________________________
Student Signature Proctor Signature
Test proctors will not answer or clarify exam questions. Questions will be referred to the course’s professor for clarification. If
the professor cannot be reached during the exam, the student will decide to answer the question.
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