LOUISIANA STATE UNIVERSITY ALEXANDRIA
Testing Accommodations Form
(Gold Form)
Exams are administered between the hours of 8 a.m. and 4:30 p.m. Monday - Friday
Student: Comp lete the following information and give to your instructor no less than 3 school days prior to the exam.
Name:
Pho ne N umb er:
Course:
Instructor:
Today’s Date:
INSTRUCTOR: In order to have this exam proctored to your specification(s), PLEA SE com plete the following information, and
return this form along with the exam to the Testing Center.
Signature of Instructor:
I un de rs ta nd th e a bo ve na m ed st ud en t w ill r ec eiv e a cc om m od at io ns on th e t es t t o b e a dm in is te re d a s lis te d b elo w .
Pho ne N umb er:
Office Room N umber:
Course:
Today’s Date:
Start exam by this date/time:
Finish exam by this date/time:
AIDS ALLO WED : (No aids will be permitted unless specifically authorized)
G Calculator________________
G Notecard G 3" x 5"
G 4' x 6'
G Computer Exam
G 5" x 7"
G Colored Paper ____________
G Reader
G Scantron 2052 (blue, 1-100, 1-5)
G Dictionary
G Scribe
G Scrantron F-165 (red. 1-100, A-E)
G Enlarged Exam
G Textbook __________________
G Formula Sheets
G Translation Device/Book ______
G Notes ____________________
G Blue Book __________________
G _______________
G Scantron 881E/ES (green, 1-50, A-E)
G Scantron 882E/ES (green, 1-100, A-E)
G Other _________________________
_______________________________
Scantrons are p rovided by the instructor or student
G Extended Time:
(Time & ½ or double time)
SPECIAL INSTRU CTIONS:
Exam Return: Return to (Building/Room #):__________________________________ I will Pick up the exam:_______________
Student Services - Testing
Phone: 318-427-4492
Fax: 318-473-6580
Email: kcooley@lsua.edu