Proctor Request Form

We require at least 7 days notice to guarantee the accommodation.

We will still accept late forms and will make every effort to accommodate, we just cannot make any guarantees without a week's notice.

Please do not submit forms more than 2 weeks in advance.

STUDENT SECTION

Student's Name *

Student's CWID *

Student's Email *

Campus *

Course Name *

Student Major*

Requested Accommodations

I have read and understand the rules and protocols for using testing services with The Office of ACCESSibility.*

Yes

PROFESSOR SECTION

FOR PROFESSORS TO FILL OUT ONLY.

STUDENT, DO NOT FILL OUT THIS SECTION.

The professor should fill out a hard copy and give it to the student to upload.

OR

The professor should fill out the digital form below.

Click on the link below to download a hard copy of the Professor Section to upload.

Printable Form (PDF)

If your professor filled out the paper version of the Professor Section, please upload it here.

No File Chosen

File uploads may not work on some mobile devices.

Professor Information

Instructor's Name *

Instructor Email*

Instructor's Phone*

Department*

Exam Information

Date and time of exam*

:

Actual amount of time that class receives for exam (hours/minutes): PLEASE DO NOT CALCULATE THE ACCOMMODATED TIME, OUR OFFICE WILL DO THIS*

Will lecture resume after the exam?*

Yes No

What time should the student return to class for lecture?

Due to limited hours, it may be necessary to arrange testing at an alternative date/time than the regular class exam.

Dobbs Ferry available testing hours: 9 AM–5 PM, Mon–Fri or by appointment
Bronx and Manhattan by appointment

Please indicate an alternative date and time to take the exam:

:

How will professor deliver exam to ACCESSibility Office? *

Email (accessibility@mercy.edu) Professor will drop off Student will bring with them in a sealed envelope Examsoft BlackBoard

Other:

How will professor retrieve completed exam? *

ACCESSibility Office should scan and email completed exam to professor Professor will come to ACCESS office to retireve exam Student will bring with them to class in a sealed envelope Examsoft BlackBoard

Other:

Students testing in the classroom are permitted use of the following items:

Example: calucalator, scratch paper, formula sheet, etc.

Additional Information/ Comments/ Questions:

Professor Signature

[clear]

Forging this signature will result in conduct sanctions.

ACCESS Notes