Proctor Request Form

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 *

Course *

Requested Accommodations

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*

:

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 appointment
Bronx and Manhattan by appointment

Please indicate an alternative date and time to take the exam:

:

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:

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:

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

COVID -19 Update

Proctor Request Form