Disability Support Services
PO Box 1510
Pembroke, NC 28372
Location: D.F. Lowry Building, Room 103
Exam proctoring Authorization form
This form must be completed, signed, and delivered to exam site before exams will be administered. It is the responsibility of the student to schedule exams with DSS at least one week prior to the test date. Testing outside the classroom or academic department is warranted only if circumstances prevent instructor from making localized arrangements or if student needs assistive technology at DSS. Failure to schedule an exam one week in advance may lead to DSS denying a specific time and date for the exam. If the student is caught cheating, the professor will be notified, and testing accommodations may be revoked. DSS staff will email the instructor if an exam is not retrieved by the end of the semester in which it was taken. An exam left in DSS after such notification will be filed in the respective student’s file.
PLEASE PRINT CLEARLY :
Student’s Name: _______________________________________________
Course Name and Number: ______________________________________
Exam Date: _________ Exam Time: _________Exam Location: ________
Student Signature: ________________________ Date: _______________
Please initial all pertinent rules and mark through those rules that do not apply (to be filled out by the instructor)
_____ Book(s) may be used:
_____ Notes may be used
_____ Dictionary may be used
_____ Calculator may be used
_____ Scratch paper may be used
_____ Student may keep test questions
_____ Student may keep scratch paper
_____ Other – Please Explain:
Time allotted for the class to take the test: ____
Instructor’s Name: ______________________________________________
Instructor’s Signature: ___________________________________________
Office Address: _________________________________________________
Instructor’s Phone: ______________________________________________
Departmental Phone: ____________________________________________
I will pick up the test on ____________________ at ___________________
(Office Use Only)
Date Exam Received: _____________ Staff Initials: ______
Date Exam Administered: __________ Time Started: ______
Ended: ______ Staff Initials: _________
Pick up: ________________________________________________
Instructor/Staff Signature Date
I decline the recommended accommodations for this exam and waive the right to use these accommodations.
Student’s Signature: _________________________________________ Date: _________
Disability Support Services (DSS) offers exam accommodations for students with disabilities such as extended time, alternative formats, and assistive technology depending on the student’s disability. These accommodations are implemented to give students with disabilities equal access to testing and accommodates for certain limitations related to the student’s disability.
Testing outside the classroom or academic department is warranted only if circumstances prevent the instructor from making localized arrangements or if student needs assistive technology at DSS. Therefore, when testing accommodations or alternative testing is needed, students are responsible for discussing this issue with the professor to make the appropriate arrangements to have the exam administered. It is the responsibility of the student to schedule exams with DSS at least one week prior to the exam date. Failure to schedule an exam one week in advance may lead to DSS denying the requested time and date for the exam. DSS will make every effort to accommodate students in a timely and reasonable manner.
Standard testing procedures for DSS:
Students who arrive at DSS late for an exam may have this time deducted from their scheduled testing time, as in the case of classroom testing. If a student does not come in to take a scheduled exam at DSS, the examination will be sent back to the professor. Therefore, students must have the professor approve any change in time of administration of exams before DSS will make an appointment to reschedule proctoring the exam again.
Thank you for your assistance in this testing process!
Updated: Wednseday, December 1, 2010
© The University of North Carolina at Pembroke
PO Box 1510 Pembroke, NC 28372-1510 • 910.521.6000