Sample Test Accommodation Form
CONFIDENTIAL
DSS TEST ACCOMMODATION REQUEST FORM
The student is responsible for returning the completed form to DSS a minimum of 5 working days in advance
of the first listed test date. Not doing so may cause delays in the scheduling of exams.
Student Information (Student should complete this section.)
complete this section.)
Course Information (Student should
Name
Class
Phone
Instructor
Email
Instructor Email
Accommodation Information (DSS Staff should complete this section.)
Private Room
Semi-Private Room
Scribe for Scantrons
Scribe for Essays
Reader
Time and a Half
Double Time
Computer
JAWS Computer
Dictionary
Other
DSS Staff Signature
Date
Student Signature
Date
Exam Dates & Times (Extended time accommodation should be accounted for in begin and end times.)
Exam Date
Begin Time
End Time
Exam Received
Exam Instructions (Instructor should complete this section)
The student should be allowed to use the following instruments/materials during the exam (Check all that apply.):
Open Book Use of Notes Use of Calculator Use of Formula Sheet
Scantron Form
Other Special Instructions
Use of Periodic Chart
Instructor Signature
DSS Staff Signature
Date
Date
Use of
Disability Support Services Exam Service
Dear Faculty & Students:
DSS’s Exam Service is provided by Disability Support Services (DSS) as a service to faculty and students. DSS
administers exams under accommodated conditions to students with disabilities who make timely requests for these
services. DSS is committed to providing accommodated exams with the integrity and conscientiousness expected by
faculty. When faculty, students, and DSS cooperate, disability accommodations can be appropriately provided and
academic standards maintained. The following information is provided as a means of arranging for test
accommodations at DSS.
We strongly encourage instructors who plan to use DSS to accommodate their students to
call 298-2512 with any questions or concerns.
Sincerely,
DSS Staff
Instructions for completing the Test Accommodation Request Form
1.
This form needs to be completed only if instructors plan to use DSS to accommodate students’ exams.
2.
Students should complete the student and course information sections.
3.
DSS staff completes the accommodation information section and fills in the exam dates and times with information from
the course syllabus.
4.
DSS understands that the dates for some exams are to be announced. If this is the case, TBA indicates the number of
exams that will be administered in this particular class. Students or instructors can call in the dates and times for exams
as soon as they have been announced.
5.
Instructors should indicate the additional materials (open notes/book, calculator, etc.) that are allowed during exams by
circling the appropriate choices. If a calculator is allowed, please specify the type of calculator that has been approved.
In addition, please include any other specific instructions that DSS will need to administer the exam.
6.
Instructors should keep the white copy and give the other copies back to the student.
7.
Students should return the yellow and pink copies to DSS at least 5 days in advance of the first date listed on the form.
When DSS receives and signs the forms, the pink copy will be given to the student.
DSS Responsibilities
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DSS’s exam services will operate Monday through Friday from 8:00 AM to 4:00 PM. This
service remains in operation over the lunch hour.
DSS is responsible for ensuring that all exams remain secure.
DSS is responsible for ensuring that students only use materials approved by instructors
during exams.
DSS will notify faculty of cheating or suspicious behavior on the part of the student.
DSS will provide appropriate accommodations that are requested in a timely manner
DSS will hand deliver exams to the main department offices upon completion.
If we have not received exams from instructors, DSS will send a reminder email the day before
the exam is to be administered. If the text needs to be converted to an alternative format, such
as Braille, instructors may receive a reminder several days in advance.
Student Responsibilities
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Students are responsible for scheduling a meeting with DSS staff to complete the Test
Accommodation Request Forms at the beginning of each semester.
Students are responsible taking the test forms to their instructors for approval and a signature.
Students should NOT leave the forms with their professors to be completed at a later time.
Students should NOT assume that the instructor will return the forms to DSS.
Students should discuss needed accommodations and testing arrangements with their
instructors.
Students should leave only the completed white copy of the form with their instructor.
Students are responsible for returning the completed pink and yellow copies of the forms least
5 working days in advance of their first scheduled test.
Students are responsible for showing up on time for scheduled exams.
Students should take only the materials needed to complete the exam into the exam room. All
personal belongings should be left in the main DSS office while exams are in progress.
Students are responsible for contacting DSS with exam dates and times when tests are to be
announced or when a test is rescheduled.
Instructor Responsibilities
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Instructors are responsible for providing requested test accommodations within their
department or using the DSS exam service to provide those accommodations to their students
who have provided them with appropriate documentation (Accommodation Letters and Test
Accommodation Request Forms).
Instructors should discuss needed accommodation and testing arrangements with their
students.
Instructors are responsible for completing their designated section of the Test Accommodation
Request Form and retaining the white copy for their records.
Instructors are responsible for ensuring that DSS receives a copy of the test in a timely
manner. Tests can be faxed to 298-2361, emailed to disability@wiu.edu, or delivered to Seal
Hall, Room 117.
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Instructors are responsible for ensuring the student’s confidentiality throughout the semester
and appropriately maintaining all confidential communications with the student and DSS (i.e.
accommodation letters, white copies of the test form, emails).