Student Services

Disability Services

Disability Services Exam/Test
Proctoring Request Form

Exam/Test Proctor

Cherish Tijerina Pearson
Disability Services Coordinator

West Building 269 J

Instructor's Name:
Student's Name:
Course Prefix/Number (i.e. Engl 101):
Instructor's email:

Exam/Test Information

Length of exam/test in the classroom:

Please indicate the actual exam/test time in the classroom:

Regular Exam/Test Day:

Regular Exam/Test Date: mm/dd/yr

Regular Exam/Test Start Time: hr: mins/am or pm


Student is allowed the following during the exam/test:

No. 2 Pencil


Scratch Paper


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


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

I (the instructor) will e-mail the exam/test to the proctor at

I (the instructor) will deliver the exam/test to Disability Services.

I (the instructor) will send the exam/test through campus mail in a sealed interdepartmental envelope.

How would you like the exam/test returned to you?

I (the instructor) will pick up the exam/test from the Disability Services office.

Date (2/20/12): Time:

Put in campus mail in a sealed envelope.

Scanned and e-mailed back to me (the instructor) in a PDF file.

Questions or Comments: