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Instructor's Test Accommodation Form
Please fill this form out accurately and completely. Fields marked * are required.

*Name of Student: 
*Instructor: 
*Course Name: 
*Course Number: 
*Time given to class (ex: 1 hr 20 min): 
*Day class is scheduled to take exam:
*Date class is scheduled to take exam: 
*Time class is scheduled to take exam: 
*AM/PM:
*Do you permit student to take exam at a
time other than what is indicated above?
*If the student has questions during the
exam, how may we contact you?:
 
Please check all items below that pertain to the exam
Blue Book
Closed Book
No Notes
Open Book
Class Notes
Scantron
Computer
Calculator
Notes must be turned in with exam
Special Instructions (Limit to 4000 characters): 
How will Student Success Center receive test?
*Choose one
Please Note: If student has an accommodation of "audio formatted tests", an e-mail with the test attached, in Word or PDF format, must be provided to the Student Success Center at least one day prior to the test date.
Return Instructions:
*Choose one:
Verify and Submit
By submitting this form with SID verification I acknowledge that all the information on this sheet has been approved by me and that I am aware of the testing guidelines that are enforced by DSS.
Employee SID
PIN