Exam Proctoring Request Form
Pepperdine University - Disability Services Office
TCC 264
Phone: (310) 506-6500 Fax: (310) 506-6776 More copies of this form are available online at:
*Authorized date/time change: _____________________ _____________ Professor’s initials: ________________
(date) (time)
To be Completed by the DSO Student (this form is required for EACH exam- multiple test dates will NOT be accepted)
Name: _________________________________________ Campus Wide ID Number: __________________________
Course Name and Number: _____________________________________________________________
Exam Date: ______________ Exam Time: _________________
Type of Accommodation Requested (mark with an “x”): Extended-Time: ____ Distraction-Reduced Site: ____ Computer: _____
Other: _____________________________________________________________
I understand that it is my responsibility to arrange for the completion of this form and the scheduling of my exam with the Disability
Services Office (DSO)
at least seven (7) days [14 days for final exams] prior to test administration. If an exam time or date
change is required, I will need to reschedule with my professor and provide the DSO with authorization from the professor for any
changes (through an amended proctoring form*(see below), phone call, or email). I am aware that my time may be deducted accordingly
in the event that I am late for an exam and my accommodations may be forfeited.
Student’s initials: _____________ Date: ______________
To be Completed by the Professor (this portion MUST be completed by the professor, NOT the student)
Professors are encouraged to provide the approved reasonable accommodations to their students during the scheduled exam meeting time and
place. However, if it is preferred by the professor or the student to ask that the DSO administer the exam, this form is used to make the request,
indicating an agreement between the PROFESSOR and the STUDENT. This request is being made in accordance with federal and state laws and
regulations that govern support services to students with disabilities. Feel free to contact the DSO at x6500 if questions arise.
Professor’s Name: ______________________________________________ Office: ________________ Extension: ____________
Please indicate procedures to be used during the test (Open Book, Notes, Calculator, etc.):
If the proctor is permitted to contact you during exam administration, please provide contact information:
(phone/email address)
Standard Length of Exam: _________________ (the time allotted to the rest of the class)
Pre-Test Pick-up Instructions: Post-test Return Instructions:
____ Professor/TA will fax/email to DSO on __________________ ____ DSO will fax/email exam to ____________________________
(date) (email address/fax #)
____Professor/TA will deliver to DSO on _____________________ ____ Professor/TA will pick up exam on ______________________
(date) (date)
____ Student will deliver to DSO (in sealed envelope) ____ Student will return exam (in sealed envelope)
____ DSO will pick up exam at _________ on/at ________________ ____ DSO will return exam to ___________
(room #) (date/time) (room #)
Additional Instructions: _______________________________________________________________________________________________
Professor’s initials: ____________ Date: __________________
**Completed form should be returned to the DSO at least seven (7) days [14 days for final exams] prior to test administration via fax, email
(DSO@pepperdine.edu) or hand-delivery (NOT campus mail).
By signing this portion of the form, I understand that I will be held accountable for the information provided including standard length of the
exam and the means by which DSO will acquire the exam. It is my responsibility to promptly inform the DSO of any changes made to the
pre-test pick-up instructions or the post-test return instructions. I will immediately contact the DSO in the event that the exam has been postponed
or re-scheduled due to my absence.
Office Use Only
Received by:
Initials: _________
Date: ___________
Please open this form in Adobe Acrobat
Reader (NOT Mac Preview). If you are
accessing this form via our website, save a
blank copy to your personal desktop, close
the website, then complete the form using
the version you saved to your desktop.
SAVE AS & email to professor as ATTACHMENT
Submit Form to DSO