Exam Request Form

Today's Date: 12/1/2023

*Student First Name:

*Student Last Name:

*Student Email:

*Name of the course:

*Instructor First Name:

*Instructor Last Name:

*Date that the class is taking the exam:

*Time that the class is taking the exam:
to
*Date student is requesting to schedule the exam (Must allow 48 business hours in advance):

*Time student is requesting to schedule the exam:
to
*Do you need a computer or technology for this exam?
yes
No

Will you be using a computer or assistive technology for this exam?
I am permitted to use my own laptop for this exam
I need a testing center computer
My exam is administered using Respondus lockdown browser
I need a keyboard/to type or a spellchecker as an accommodation
I need assistive technology

*Please list accommodations you need or any other information you would like to tell us about the exam, other than extended time. Please note: exams that require a reader and/or scribe need to be requested one week in advance to allow for staff scheduling. :

*Please type the word