Semester____________
Student Name____________________________________________
Class____________ Section ___________ Location_________________________
Day/time___________ Testing Location___________________________________
Instructor____________________________________________________________
Office _________________________ ext. _____________
Student has requested the following test accommodations
[ ] Extended Time [ ] Test on Computer [ ] Interpreter [ ] Enlarged Print
Student has my permission to take the exam/quiz.
[ ] Only on the same day and the same time as the class.
[ ] Only on the same day as the class, but at another time.
[ ] Before the same day and same time as the class.
[ ] On any day and time other than the class.
[ ] Instructor will administer all tests to the student.
Students must obtain written or verbal approval to reschedule test: yes [ ] no [ ]
DSS will obtain exam/quiz in the following manner:
[ ] Always at the beginning of the class exam
[ ] Always from the department secretary.
Name_________________________Location_______________________________________ext._______
[ ] Instructor or Dept. Rep. will always deliver exam/quiz to DSS.
Deaf Students services will always return the exam/quiz back to the
department by 4:30 PM on the same day as the test. If the student's
test time prohibits the return of the exam/quiz by 4:30 Pm, it will be
returned to the dept. the next business day before 4:30 PM.
Instructor Signature___________________________________Date___________
Return this form upon receipt to: Shirley Rivard, Interpreter Coordinator, Turley House 1