Accommodation Test Request Form
Completed by Student
Student Name: Student ID: Date:
Requested Exam Date: Requested Exam Time: ___:00 or ___:30 Class meeting times per week: ____
Course Name and Section: Professor Name:
Approved Requested Accommodations: ____% Extended time: ___Distraction Reduced
☐ Word Processor/Comp ☐ Text to Speech ☐ Speech to Text
☐ Scribe ☐ Reader ☐ Other:
Students, do not continue below this line. Save and send this PDF to DisabilityServices@ccsu.edu
Completed by Professor
Professor Name: Course:
Date of Exam: Allotted test time for class:
Please check any exam allowances: ☐ calculator ☐ open notes ☐ open book ☐ formula sheet
☐ scrap paper ☐ Blue books ☐ scantron sheet ☐ other:__________________________________
Delivery: ☐ Will drop off exam ☐ Will email exam
Return: ☐ Will pick up exam ☐ Exam emailed
Office Use
Start proctor: __________________ Actual Time Started: _______________________
End proctor: ___________________ Allotted End Time: _________________________
Actual End Time: _______________________
Comments: _________________________________________________________________________
Date: ____________________
Professor/Dept. Secretary signature: _______________________________ Date:_____________________
CCSU
Central Connecticut State University
Student Disability Services
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