The University of Northern Iowa Examination Services
In association with Student Disability Services
EXAM ACCOMMODATION REQUEST FORM
Exams with accommodation are encouraged to be made and directed by the class instructor. Instructors may utilize their
own department rooms to fulfill needed accommodations. If instructors are unable to make arrangements, Examination
Services may be able to administer the exam with a one week notice. Testing hours are currently 10:30 a.m. – 4 p.m.,
Monday – Friday. To schedule an exam, please complete the following and deliver the form to Examination Services in
the Academic Learning Center, 007 ITTC. If you have questions, please call Examination Services at 319-273-6023.
STUDENT INFORMATION
Student Name:___________________________
Student phone: _________________________________
Student email: ___________________________
Student ID: ____________________________________
COURSE INFORMATION
Course name: ____________________________
Course number: __________________________________
Instructor name: __________________________
Department: _____________________________________
Instructor phone: __________________________
Instructor email: ___________________________________
If the student has a problem or question regarding the exam, can we contact you at the number listed above? ___Y __N
If no, please provide an alternative phone number or contact that we may reach for questions: ______________________
EXAM INFORMATION
Please complete this form for all exams you are requesting to have administered by Examination Services. Depending on
scheduling and availability, Examination Services may not be able to administer an exam on a specific day/time. If
possible, Examination Services will work with the student and instructor to arrange an alternative date/time.
Exam 1
Requested exam date: ___________________________Requested exam time: _________________________________
How many minutes does the rest of the class have to take the exam? _________________________________________
Exam 2
Requested exam date: ___________________________Requested exam time: _________________________________
How many minutes does the rest of the class have to take the exam? _________________________________________
Exam 3
Requested exam date: ___________________________Requested exam time: _________________________________
How many minutes does the rest of the class have to take the exam? _________________________________________
Exam 4
Requested exam date: ___________________________Requested exam time: _________________________________
How many minutes does the rest of the class have to take the exam? _________________________________________
Final Exam
Requested exam date: ___________________________Requested exam time: _________________________________
How many minutes does the rest of the class have to take the exam? _________________________________________
ADDITIONAL EXAM RESOURCES ALLOWED
__ Articles/Readings
__ Calculator:
__ Simple
__ Scientific
__ Course packet
__ Dictionary
__ Formulas
__ Internet access
__ Notes
__ Note card(s)
__ Scratch paper
__ Textbook
__ NONE
__ Other:_________________________________________
ADDITIONAL EXAM ADMINISTRATION INSTRUCTIONS
_______________________________________________________________________________________________
DELIVERY OF THE EXAM TO EXAMINATION SERVICES (Select One)
__ Email (Word or PDF):
o To: marcy.gosse@uni.edu
o cc: michelle.galanits@uni.edu
__ Hand delivered by instructor to Examination Services
INSTRUCTOR TO RECEIVE COMPLETED EXAM (Select One)
__ Email (PDF)
__ Fax
o
To: _______________________________________________________________
__ Pick up from Examination Services
If another individual (not the instructor) will be picking up the exam, please provide his/her name and title:
o
Name: _________________________
Title: _______________________________
By signing this form, I acknowledge that I understand and agree to follow the policies and procedures set forth by
Examination Services for the use of their facility in administering exam accommodations.
Chapter 22 Code of Iowa: This information is requested to provide examination accommodations. Only directory
information may be released to third parties. All items are required and therefore incomplete forms may not be processed
____________________________________________________________________________________________
Instructor Signature
Date
____________________________________________________________________________________________
Student Signature
Date