Skip to Quicklinks
Skip to Quicklinks
Contact Information

Disability Support Services
PO Box 1510
Pembroke, NC 28372

Phone/Voice: 910.521.6695
Fax: 910.521.6891
TTY: 910.521.6490
Email: dss@uncp.edu

Location: D.F. Lowry Building, Room 111
Campus Map

 

 


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.

*** Exams may be picked up or dropped off during departmental hours only ***

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:

Title:___________________________________________________________

_____ 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: ____________________________________________

Date: _________________________________________________________

I will pick up the test on ____________________ at ___________________

 


(Office Use Only)

Date Exam Received: _____________ Staff Initials: ______

Date Exam Administered: __________ Time Started: ______ Ended: ______ Staff Initials: ______

Comments: _______________________________________________________________

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: _________
06/08

 

Updated: Thursday, June 19, 2008

Return to Forms

 

© The University of North Carolina at Pembroke
PO Box 1510 Pembroke, NC 28372-1510 • 800.949.UNCP (8627) • 910.521.6000