Revised 1/15/20
Testing Services Request Form
Student Name: Test Date(s):
(For web courses, attach list of student names)
Instructor: Course Number:
INS
TRUCTOR:
To ensure students are tested under the conditions you d
esire, please answer all questions on this form.
Typ
e of test
On Computer Paper/Pencil
Typ
e of course:
Face-to-Face Hybrid Web-based
Other:
Other test location besides Yuma Campus:
San Luis Somerton Parker MCAS Quartzsite Wellton
Other:
Desired Testing Conditions:
Timed test? Yes No Duration:
Allow notes? Yes No Comment:
Allow books? Yes No Comment:
Allow calculator? Yes No Comment:
Allow breaks? Yes No Comment:
Additional Comments:
OFFICE USE ONLY
Re
cord#___________ LK#________Testing Station#________ Notes: Y N ID TYPE:________________ INT:_______
Te
st taker signature__________________________________________________________________Date____/____/_______
Time IN:____________ Time OUT:____________ Break Start:____________ B
reak End:____________
Pick-up Sig
nature:__________________________________________________________________________ Date_____/_____/______
(Delivered by: E-Mail FAX MAIL) Date Sent: ______/______/______ Time Sent:______:_______ INT:_______
• Make-Up Exams: one intake form is needed for each student
• Paper/Pencil Exams: attach a test for each student
• Please note: Testing Center staff are NOT available to SCAN, FAX or Email exams
