Disability Resource Center 125 Hahn Student Services Building Phone: 831-459-2089
Fax: 831-459-5064
Email: sumexams@ucsc.edu Website: http://drc.ucsc.edu
DRC Summer Exam Request Form
1. Course Information
Course:___________________ (ie. MATH 19A)
Session: __________
Class Room- Building ________________________
Room: ____________
Instructor Name: __________________________________________________
Instructor e-mail: __________________________________________________
Instructor phone: __________________________________________________
Department: ______________________________________________________
2. Exam Information
We strongly encourage you to submit the DRC Exam Request Form listing all of your
Summer Session class’s exams early in the session.
Date of Exam (s): ___________________ Start Time: _______ End Time: _______
(Without extended time)
___________________ Start Time: _______ End Time: _______
(Without extended time)
___________________ Start Time: _______ End Time: _______
(Without extended time)
___________________ Start Time: _______ End Time: _______
(Without extended time)
What materials are students allowed during the exam:
________________________________________________________________
Will you or a TA be available to answer student questions testing in the classroom?
__________No __________Yes
If Yes, who will be available for questions during the exam to students testing with
accommodations?
Name ____________________________
Title ______________________
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How will they make themselves available? _________________________________
What kind of exam support are you requesting?
_____ Exam Room(s)
_____ Proctor
_____ Scribe
_____ Reader
_____ Other: _____________________________________________________
Requests for testing rooms, proctors, scribes or readers should be made at least 5
business days in advance if at all possible.
3. Please list ALL students who have presented Accommodation Authorization Letters
and made request for exam accommodations:
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
4. Where should the proctor pick up the exam?__________________________________
You must provide a pick up location for the exam or e-mail a copy of the exam to be
administered to sumexams@ucsc.edu no later than noon the day before the exam.
5. Where would you like the completed exam delivered? ____________________________
Unless a specified drop off location is indicated the completed student exams will be
delivered via e-mail to instructor no later than noon one business day following the
exam date, sooner if possible. Alternate delivery can be arranged as well.
6. Please complete this form and e-mail it to: sumexams@ucsc.edu or fax it to: 831-4595064.
For Admin Use Only-------------------------------------------------------------------------------
Received Date: _________________
Room(s) Request sent to Summer Session, Date: _____________________
Exam Room(s) Assigned: ___________________________________________
Proctor/Reader/Scribes(s):___________________________________________
Exam received Date: _______________________________________________
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