Instructor Proctoring Request

Institution:

Test Site:

Requestor's Name:

Department:

Mailing Address:

City:

State:

Zip Code:

Contact Phone:

Fax Number:

Contact Email:

Name of Test:

Course Name:

Proctor Site Authorization/Confirmation:

Deadline:

xx/xx/xxxx

Time Limit::

Test Format:

Online

Paper

If Online, What is the URL of the test?:

If Applicable, what is the username?:

If paper-based exam::

How many pages is the exam?

If paper, return or deliver by::

Mailing Address

Fax

Email Attachment

Return to instructor by the following date::

xx/xx/xxxx

Student(s) Name::

What forms of identification are acceptable?:

Exam Question 1:

What resources/items can the examinee have in the testing lab? (I.E. open book, highlighters, calculators, notes, etc.)

Exam Question 2:

What specific instructions do you have for the proctor when administering the exam?

Additional Information: