Requests must be made one week in advance unless other arrangements have been approved by Learning Support Services.

Name:  

Email:  

Phone: 

Date:    

Date instructor announced the exam: 

Please answer the questions below.

1.  What alternative testing needs have been approved by Learning Support Services for you?  (Check all that apply.)

Quiet Environment
Scribe
Taped exam/reader
Time and a half
Double Time
Computer
Calculator
Print Enlargement
Other (Please List)

2.  Please list the name of the course and the name of the instructor.

 Course:     Instructor:

3.  Please list the date and time of the test scheduled for your class.

Choose One Monday Tuesday Wednesday Thursday Friday  Date:  

Class Start Time:     
Class End Time:   

4.  If you use extended time on your tests, please indicate whether you have extra time before or after your class.

before
after 

5.  Any additional notes:

When completed, please click "Submit."  Someone will contact with within two business days to process your request.  If you do not receive a telephone call or an email, contact Deb Tobin immediately.