Home Student Support Office Of ACCESSibility Information For Current Students Proctor Request Form Proctor Request Form Proctor Request Form Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields We require at least 7 days notice to guarantee the accommodation. We will still accept late forms and will make every effort to accommodate, we just cannot make any guarantees without a week's notice. Please do not submit forms more than 3 weeks in advance. Student Information Student's Name * Student's CWID * Student's Email * Campus * - Select a campus - Dobbs Ferry Bronx Manhattan Distance Learning Course * Requested Accommodations Accommodation Options Reader Extended Time (1.5) w/ separate location Scribe Scrap Paper Double Time w/ separate location Word Processor Other: Other Value Instructor & Exam Information Instructor's Name * Instructor Email* Instructor's Phone* Department* Is this exam for a NURSING student? * Yes No Is this exam an ATI or Kaplan exam? * ATI Kaplan No, not an ATI or Kaplan exam Exam Information Student, please work with your professor to complete the section below and ensure all information is accurate. Discrepancies with exam information will delay processing. Date and time of exam* https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 Hour 01 02 03 04 05 06 07 08 09 10 11 12 Minute : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM/PM AM PM Actual amount of time that class receives for exam (hours/minutes): * Will lecture resume after the exam?* Yes No What time should the student return to class for lecture? Due to limited hours, it may be necessary to arrange testing at an alternative date/time than the regular class exam.Dobbs Ferry available testing hours: 9 AM–5 PM, Mon–Fri or by appointmentBronx and Manhattan by appointment Please indicate an alternative date and time to take the exam: https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 Hour 01 02 03 04 05 06 07 08 09 10 11 12 Minute : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM/PM AM PM How will professor deliver exam to ACCESSibility Office? * Email (accessibility@mercy.edu) Professor will drop off Student will bring with them in a sealed envelope Examsoft BlackBoard Other: Other Value How will professor retrieve completed exam? * ACCESSibility Office should scan and email completed exam to professor Professor will come to ACCESS office to retireve exam Student will bring with them to class in a sealed envelope Examsoft BlackBoard Other: Other Value Students testing in the classroom are permitted use of the following items: Example: calucalator, scratch paper, formula sheet, etc. Additional Information/ Comments/ Questions: ACCESS Notes Previous← Next→ Enter your save and resume password Cancel Confirm