Office of Student Disability Services
500 College Avenue, Parrish Room 113, Swarthmore, PA 19081-1397
Leslie Hempling – Phone: 610-690-5014 Fax: 610-328-8487 Email: lhempli1@swarthmore.edu
EXAM PROCTOR REQUEST FORM 2015-2016
INSTRUCTIONS: Faculty members unable to proctor an extended time final exam may submit a request for the
student to take his or her exam in group testing classrooms that will be set aside for the Student Disability Service.
For other tests during the semester, we may be able to help you locate a space and a proctor with enough notice.
To request help, the faculty member should complete both pages of this form. Have your student sign below so
that he/she understands these arrangements. The instructor may email the form to Diane Watson at
dwatson1@swarthmore.edu or deliver to Diane in Parrish 119 West.
DEADLINE: Submit no later than 3 weeks before final exams. (November 20 for Fall ’15; April 15 for Spring ’16.)
For help with other tests, please submit at least 2 weeks before a test. Thanks very much!
STUDENT INFORMATION
Name: _______________________________________
Class Year: __________________
Email: _______________________________________
Phone: ______________________
INSTRUCTOR & STUDENT SIGNATURES
I understand that the Disability Service will arrange a proctor and room for the test/exam listed on this form. The
instructor is responsible for coordinating test delivery and pickup with the Disability Service. The student is responsible
for following instructions given by the instructor and Disability Service regarding test procedures. The Disability
Service will email the student and instructor with all details regarding location, time and logistics at least one week
before a final exam and 24-48 hours before a test.
Instructor Signature: ________________________________
Date: _____________________
Student Signature:
Date: _____________________
________________________________
TO BE FILLED OUT BY COURSE INSTRUCTOR
Please complete the information below and on page two so that we can be sure that your exam is
implemented correctly.
Instructor Name: _____________________________________
Email: ________________________
Office phone: _____________________________ Cell phone: _________________________________
Contact Phone # and/or Email if student has questions during test: __________________________________
Updated 8/31/15
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TO BE FILLED OUT BY COURSE INSTRUCTOR
Course Name: _____________________________________
Course #: __________
Day & Time course normally meets: ___________________________________________
___This is a final exam
___This is a test during the course of the semester
Regular Test Date & Time: ___________________ Regular Test Location: _____________________________
Number of minutes allotted for standard test administration: _____________________
Closed Book
Notes
Calculator
Y N
Y N
Y N
Open Book Y N
Slide identification Y N (e.g., art history)
Index Cards Y N
Type of calculator allowed: ____________________________
Other Allowances: ___________________________________________________________________
Accommodations for this Student
____ 50% extended time
____ 100% extended time
_____Distraction-Reduced room
____Ability to stop clock and leave room if medically necessary
____Use of clean laptop
____Voice Recognition software
____Scribe
____ JAWS/Screen reader
____Reader
Other Accommodations: ________________________________________________________________
TEST DELIVERY: If your final exam is scheduled to begin at 9:00 AM or 2:00 PM, our proctor will pick up the
exam from you (the instructor) 10 minutes beforehand in your regular exam location. If the final is scheduled
for 7:00 PM, please deliver the exam to Diane Watson (Parrish 119) 48 hours in advance. Please do not use
campus mail.
___ This is a 9:00 AM or 2:00 PM Final Exam, I will meet the Disability Service proctor 10 minutes before the exam in the
regularly scheduled exam room to give him/her a copy of the exam plus green books.
___ This is a 7:00 PM Final Exam. (PLEASE BE SURE TO PROVIDE GREEN BOOKS WITH THE EXAM.)
___ I will bring the exam to Leslie Hempling, Parrish 113, 48 hrs. in advance. (Pls. do not use campus mail.)
___ I will email the exam to Leslie Hempling at lhempli1@swarthmore.edu.
TEST RETURN (Students are not permitted to return their own tests.)
___ I give permission for the proctor to slide the completed exam under my office door. (Exams will be in sealed, signed
envelopes.) Office Location & Room Number: _____________________________________
___ I will arrange to pick up the completed exam from Diane Watson in Parrish 119 West.
Updated 8/31/15
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