THE OFFICE OF DISABILITY SERVICES
NEW YORK CAMPUS
8TH FLOOR
NEW YORK, NY 10038
PHONE: (212) 346-1526
FAX: (914) 989-8047
FAX: (212) 346-1530
TESTING ACCOMMODATIONS REQUEST FORM
Instructions: It is the student’s responsibility to return this form FULLY COMPLETED to the Office of Disability Services in
order to arrange exam accommodations, 7 days prior to exam date. For final and midterm exams, this form is due 10 days before
the exam date. Exam hours: Monday, Wednesday, Friday 9-5; Tuesday, Thursday 9-7. Arrangements for exam
administration outside this schedule will require approval by the Office of Disability Services.
STUDENT INFORMATION - MUST BE COMPLETED BY STUDENT:
Name: _______________________________________
Pace E-mail: _________________________@pace.edu
Semester: _________________
Course Name & Number: ____________
Class Exam Date: ______________________________
Professor: __________________
Class Exam Time: ___________________________
Which of your approved accommodations do you require for this exam? (Please circle each.)
Extended Time
Calculator
Computer
Reader
Scribe
Other: _________________________
Student Signature: ______________________________________________________________________________
FOR EXAM CONFLICTS:
Students and Professors must complete this section TOGETHER if student’s schedule conflicts with the exam
period. Arrangements will be confirmed by ODS Staff. Exam hours are Monday, Wednesday, Friday 9-5;
Tuesday, Thursday 9-7.
Alternative Date: _______________________________
Alternative Time: ______________________________
Student Signature: ______________________________
Professor Signature: ____________________________
INSTRUCTOR INFORMATION - MUST BE COMPLETED BY PROFESSOR:
Amount of time class receives for exam (ODS will increase accordingly): _____________________________
All students are allowed the use of the following:
□ IF NO AIDS ARE ALLOWED CHECK HERE
□ Open Book, Class notes, Textbook: ____________________________
□ Calculator (circle): Graphing
Scientific (non-graphing) 4 Function
□ Computer (circle):
With Internet
Without Internet
□ Formula Sheets, Tables (please specify): ________________________
□ Other: ___________________________________________________
Email: _______________________________________
Phone: _______________________________________
How can we contact you if the student has a question during the exam? ___________________________________
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How will ODS receive your exam?
Professor will drop off: ___________________
Exam will be emailed to Accommodations
Coordinator (accommodatedtesting@pace.edu)
Exam will be faxed to ODS at (914) 989-8047
Other: ________________________________
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Return information for exam:
Instructor will pick up exam at ODS
ODS will e-mail scanned copy of completed
exam to: ____________________________
Exam will be faxed to: _________________
Other: ______________________________
Professor Signature: __________________________________________________________________________
I agree to have ODS administer this exam to the above student on the agreed upon time and date.
I also understand that evening exams must conclude by 5 pm Monday, Wednesday, Friday or 7 pm Tuesday, Thursday.
Please provide the exam to the Office of Disability Services 24 hours in advance of the scheduled test time.
ODS STAFF USE ONLY:
□ Schedule Exam
□
N E W
Y O R K
Confirm Exam
C I T Y

W E S T C H E S T E R
□
Receive Exam
THE OFFICE OF DISABILITY SERVICES
NEW YORK CAMPUS
156 WILLIAM STREET, 8TH FLOOR
NEW YORK, NY 10038
PHONE: (212) 346-1526
FAX: (914) 989-8047
FAX: (212) 346-1530
ODS STAFF USE ONLY
Form Received:
Form Received by: _________________________
□
Date: ____________________________________
Less than 7 days before exam? If yes, please indicate reason:
______________________________________________________________________________
______________________________________________________________________________
Accommodations Approved for Exam:
□
Extended Time:_______________________
□
Scribe: ________________________
□
Calculator
□
Reader: ________________________
□
Computer
□
Other: _________________________
Proctor Log:
Name of Proctor: __________________________________
Date: _____________________________
Amount of Time Student Receives for Exam: ____________
Room: ____________________________
Scheduled Start Time: __________________________
Scheduled Exam End Time: _______________
Actual Exam Time: ____________________________
Actual Exam End Time: __________________
Computer Used:
Computer #: ________
Yes______
No______
Notes:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
Proctor Signature: _____________________________________________________________________
After Exam:
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Copy exam for ODS files
Prepare exam for delivery
□ Pick up
□ Scan to accommodatedtesting@pace.edu
□ Student Delivery
□ Other: ____________________________
Send Delivery Confirmation
File copy of exam in ODS files
Completed by: ________________________________________
N E W
Y O R K
C I T Y

Date: _________________________
W E S T C H E S T E R