Disability Services Test Administration Request Form

DISABILITY SERVICES TEST ADMINISTRATION REQUEST FORM EMAIL ALL TESTING MATERIALS TO DISABILITY SERVICES TWO BUSINESS DAYS PRIOR TO ADMINISTRATION Eibling Hall 101 | [email protected] | Tel: 614-287-5089 I Name: n Last First s tr Contact: u Email Cell phone Work phone c t Department: Campus Address: o r Inco mplet C Current Au Sp Su e o Semester: From: (Previous semester) u Cour r se s Syno (5-digit #) e Course Name & Number: (ex. CSCI 1101) nym: Format: Classroom Blended Distance Learning

Student Name (Please Print) Date Taken DS Staff Time Start: End: (ex.Test Exam Name: 3, Quiz 2) Available Date: Deadline Date: Extended To: 2X Time Allowed (in class): Time: Hour(s) Minutes Hour(s) Minutes Student’s Testing Location: Columbus Delaware Dublin Reynoldsburg Westerville Instructor Permitted Materials: Answer format: E x Book(s) - List Specifically in Special Instructions Write answers on exam a m Calculator Type: Answer sheet provided by instructor I n Dictionary/Thesaurus Flash drive provided by instructor f Notes # of pages: Essay booklet provided by DS o r Note Card(s) # and size: Scantron provided by DS 50q 100q m Online a Formulas ti # of pages: Assessment (ex. SNAP) o n Other: Blackboard exam (Paper copy MUST be provided) NO MATERIALS ALLOWED Password:

*Office Use: T R A Special Instructions/Comments

Test Return Instructions: Mailroom Delivery Faculty Pick Up (Recommended)

Disability Services: white Instructor: yellow DISABILITY SERVICES TEST ADMINISTRATION REQUEST FORM EMAIL ALL TESTING MATERIALS TO DISABILITY SERVICES TWO BUSINESS DAYS PRIOR TO ADMINISTRATION Eibling Hall 101 | [email protected] | Tel: 614-287-5089 I Name: n Last First s tr Contact: u Email Cell phone Work phone c Department: Campus Address: Ot Received Returned ff Drop off Email IOM DS Print Interoffice Mail Faculty Pick Up i c Date: DS Initials: Date: e AQ DW DB RB WV U DS Sent to: Picked Up By: s Date: DS Initials: e DS Accommodations Provided: 2X Time Audio/Electronic Braille/Large Print Calculator CCTV Frequent Breaks Keyboard

Private Room Scribe Scribe for Scantron Spell Check Access Other:

Disability Services: white Instructor: yellow