Student Affairs

Washington State University

Disability Services Exam/Test
Proctoring Request Form

All exam/test requests must be submitted by the instructor at least 2 business days (48 hours) before the start of the exam/test or you will have to reschedule. Saturdays, Sundays and Holidays are not considered business days.

Exam/Test Proctor

Cherish Tijerina
Disability Services Coordinator
509-372-7352
West Building 269 J
ctijerina@tricity.wsu.edu

Instructor's Name:

Student's Name:

Course Prefix/Number (i.e. Engl 101):

Instructor's email:

How may we contact you if the student has questions during the exam/test:

Exam/Test Information

Length of exam/test in the classroom:

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

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

Alternative exam/test time:
Please work with student(s) to determine an alternate exam/test time. The student is expected to take the exam/test at the same time as the class unless there is a time or schedule conflict. In those instances, the student is expected to take the exam/test at the earliest available time.

Alternate exam/test day:

Alternate test date: mm/dd/yr

Alternate exam/test start time:

Student is allowed the following during the exam/test:

Scantron Sheet

Calculator

No. 2 Pencil

Textbook

Scratch Paper

Notes

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

Other:

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

I (the instructor) will email the exam/test to dstest@tricity.wsu.edu and provide a printing budget code

Enter Budget Code:

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.

I prefer the completed exam/test returned to me:

Delivered to my department inbox (copy center) in a sealed interdepartmental envelope by the exam /test proctor.

Disability Services will ONLY deliver exam/test to your department inbox, not personal offices. Exams/tests are delivered within 24 hours (business days) of exam/test completion. Student may not deliver exams/tests.

Hold for pick up

Hold instructions (i.e. phone call, pick up date, etc.)

Disability Services will hold exams/tests for 2 business days before being delivered to your department inbox office.

Questions or Comments: