Appendix I-C
Revised 07/2015
(Shaded areas are to be completed by Test
Coordinator or Examiner)
PLEASE PRINT LEGIBLY
Social Security Number: __ __ __ - __ __ - __ __ __ __
TASC Candidate First Name: __________________________ Last Name: __________________________
Date of Birth: __ __ - __ __ - __ __ __ __ Gender: M  F  Age: ____ AdultEd  Option Pathway
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Email Address: ___________________________________
Phone Number:(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Cell Number:(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Diploma: Mailing Address or PO Box ____________________________________ City: _______________
County: _______________________ State: _________________________ Zip Code: _____________
TASC – To be completed by TASC Examinee (Shaded areas are to be completed by Test Coordinator or Examiner)
Is the candidate named above retesting? Yes
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No
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The candidate named above will be taking:
Form Form Form
Reading
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Writing
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Math
Science
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Social Studies
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UUID (TASC ID)
TASC Testing Information
– To be completed by TASC test-taker
 Taking the entire test for the first time, or
 Retesting and have completed the test, or
 Taking some of the tests to complete the battery.
 Court ordered to take the TASC Tests (See attached court order).
If you have tested before, name the state/s where you tested _______________________________.
VOUCHER –To be completed by OIEP Instructor to verify the TASC test candidate’s TRA or OPT scores
The candidate named above is a first-time tester or last tested in the state of _______________ and has scored a required minimum score on the TASC Readiness Assessment (TRA) as indicated below:
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The candidate named above is a retester and has scored a required minimum on the TRA or OPT as indicated below:
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Signature of Institutional Education ABE or Option Instructor: _________________________________________________
SIGNED RELEASE-The TASC Test Candidate must sign this release section:
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I understand that the local and state Testing Coordinators and Examiners, County Boards of Education, RESAs, accredited schools that I attended, and workforce agencies with which data sharing agreements exist for the purposes of meeting national performance measurement standards will automatically have access to my records.
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I affirm that I agree to the terms set forth by CTB/McGrawHill™, the West Virginia High School Equivalency Office, and the local jurisdictions. In case of damaged or lost answer sheets or missing scores, I will be given the option to retest at this center and agree to limit the liability of all parties concerned to this free testing session.
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I also understand that if I have a disability I may apply for accommodations by contacting the Testing Coordinator for further instructions.
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I understand that no cell phones or other electronic devices are allowed in the testing room. Should a cell phone or other electronic device be found at my seat or on my person, the TASC test materials will be collected, my test scores will not be valid, and my cell phone will be confiscated. I will be required to leave the testing center. I may not reschedule to test for a minimum of six months and after the six months will need permission from the State TASC Administrator to test.
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I understand that I may not discuss practice test or TASC test items with anyone , including my teacher or family members. I understand that discussing test items may result in the invalidation of my test.
Signature of TASC Test Candidate: _______________________________________ Date: ___________
ATTACH A COPY OF CURRENT & VALID STATE OR FEDERAL ISSUED ID TO THIS FORM
ID MUST BE PRESENTED DURING EACH TESTING SESSION