Proctor Request Form

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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 SECTION

Student's Name *

Student's CWID *

Student's Email *

Campus *

Course *

Requested Accommodations

Requested Accommodations *

Reader Extended Time (1.5x) Separate, distraction reduced testing environment Scribe Scrap Paper Double Time w/ separate location Word Processor

Other: Other Value

INSTRUCTOR SECTION

FOR PROFESSORS TO FILL OUT ONLY.

STUDENT, DO NOT FILL OUT THIS SECTION.

You MUST have your professor fill this section out before you submit this request.

If your professor filled out and signed the form via the PDF version, please upload that here. You will need to transfer the "Instructor Information" and "Exam Information" sections to this online form. If you are submitting the professor's signature via PDF, you do not need to sign this online form - the PDF captures the professor's signature. Link to PDF is below.

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PDF - Instructor Section of this form

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

Date and time of exam*

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Month

Day

Year

Hour

Minute

AM/PM

Actual amount of time that class receives for exam (hours/minutes): PLEASE DO NOT CALCULATE THE ACCOMMODATED TIME, OUR OFFICE WILL DO THIS*

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 appointment
Bronx 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

Day

Year

Hour

Minute

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:

Professor Signature

[clear]

Forging this signature will result in conduct sanctions.

ACCESS Notes

Progress