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Student Affairs

Disability Exam Confirmation Form

Instructor's Name:

Student's Name:

Course Number:

Instructor's email address:

Instructor's telephone number:

Will you be available at this or another number for questions during the exam from the student?

Exam Information

Class time allotted for this exam:

Example: This may be the entire class time or may be the last 20 minutes of the class. (This is used to determine extended test time for a student with a disability).

Please indicate the following:

Class will resume after the allotted exam time.
This student will need to return to class after the allotted exam time.

I approve the time proposed by Disability Services.
I do not approve the proposed time.

Please propose alternate test times:

Alternate testing day 1:

Alternate testing start time 1:

Alternate testing day 2:

Alternate testing start time 2:

I plan to proctor the exam in my department, providing the required accomodations as outlined at the beginning of the semester.

Other:

Student may have access to:

No aids of any kind
Calculator
Tape Recorder
Textbook
Anything they choose
Notes

If notes are allowed, please describe (full notes, 1 page front and back, etc.):

Other:

Student must have the following items:

Scantron & No. 2 pencil
Blue Book
Paper
None of the above

Other (Please describe):

To facilitate the transfer of the exam to our proctor, please choose from the following options:

I (the instructor) will send a copy of the exam with the student immediately before the exam start time.
I will email the exam along with the above testing instructions to the exam proctor at
I will deliver the exam to the Student Resource Center (lower level VSSC)
I will send the exam through campus mail in a sealed interdepartmental envelope.

I prefer the exam be returned to me:

Delivered to my department by the student in a sealed envelope.
Delivered to my department by the exam proctor.
Sent through campus mail in a sealed envelope within an inter-campus envelope.