Virginia State University
Students Accessibility Office
PO Box 9030
Petersburg, Virginia 23806
Telephone: 804-524-5061 Fax: 804-524-5078
EXAM ACCOMMODATION FORM
Part 1: STUDENT: Complete Part I and give it to the professor. You will also be expected to
inform the Student Accessibility Office of your scheduled test time and date. Your contact
options are as follows by phone, fax or stop by Memorial Hall, 1
st
floor. Both steps should be
completed no less than one week (5 business days), prior to the examination.
Student: _________________________________________________ Date: ________________
Student’s Telephone Number: _____________________ Student’s Email: __________________
Professor’s Name: ______________________________ Telephone Number: _______________
Office Location: ________________________________ Office Hours: ____________________
Course Name/Number: __________________________________________________________
Date of Exam: _________________________________________________________________
Day & Time Class Meet: _________________________________________________________
Note:
Test will be taken at the same time and on the same day that the rest of the class is testing.
Part II: Professor/Instructor (Please check all that apply below):
Instructions for Proctors:
Closed Book Use of Scantron
Open Book Use of Calculator (standard or scientific)
Open Notes Blue Book Response
Special Instructions: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Professor Signature: _______________________________________ Date: ________________
THIS OFFICE DOES NOT ASK PROFESSOR/INSTRUCTOR TO MODIFY ESSENTIAL
CORE REQUIREMENTS
click to sign
signature
click to edit
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