Appendix 1-D
Revised 09/2015
(Shaded areas are to be completed by Test
Coordinator or Examiner)
UUID: _________________________
Form: ___________
Date Tested: ___________________
West Virginia TASC Form
Juvenile Centers
PLEASE PRINT LEGIBLY
Social Security Number: __ __ __ - __ __ - __ __ __ __
TASC Candidate Last Name: _____________________ First Name:
Date of Birth: __ __ - __ __ - __ __ __ __
Gender: M 
F 
Middle Initial:____________
Age: ____ WVAdultEd  Option Pathway 
Email Address: ___________________________________
Phone Number: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Cell Number: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Diploma: Mailing Address or PO Box ____________________________________ City: _________________________
County: _______________________
State: _________________________ Zip Code: _____________________
TASC – To be completed by Institutional Education Teacher (Shaded areas are to be completed by Test Coordinator
or Examiner)
Is the candidate named above retesting? Yes  No  The candidate named above will be taking:
Form
Form
Form
Reading 
Writing
Math


Social Studies 
Science 
UUID (TASC ID)
TASC Testing Information – To be completed by TASC Test Candidate
 Taking the entire test for the first time, or
 Retesting and have completed the test, or
 Taking some of the tests to complete the battery.
 Court ordered to take the TASC Tests (See attached court order).
 Is sixteen (16) years of age and may take TASC while enrolled at the center.
VOUCHER–To be completed by OIEP Instructor to verify the TASC test candidate’s TRA or OPT scores
The candidate named above is a first-time tester or last tested in the state of _______________ and has scored a
required minimum score on the TASC Readiness Assessment (TRA) as indicated below:
TRA Math 8 pts 
Reading 9 pts 
Science 7 pts 
Social Studies 9 pts 
Writing 13 pts 
The candidate named above is a retester and has scored a required minimum on the TRA or OPT as indicated below:
TRA Math 8 pts 
Reading 9 pts 
Science 7 pts 
Social Studies 9 pts 
Writing 13 pts 
OPT
Math 470 pts 
Reading 470 pts 
Science 470 pts 
Social Studies 470 pts 
Writing 470 pts 
Signature of OIEP Instructor: __________________________________________________________
SIGNED RELEASE -The TASC Test Candidate must sign this release section.
 I understand that the local and state Testing Coordinators and Examiners, County Boards of Education, RESAs, accredited schools that I
attended, and workforce agencies with which data sharing agreements exist for the purposes of meeting national performance
measurement standards will automatically have access to my records.
 I affirm that I agree to the terms set forth by CTB/McGraw-Hill™, the West Virginia High School Equivalency Office, and the local
jurisdictions. In case of damaged or lost answer sheets or missing scores, I will be given the option to retest at this center and agree to
limit the liability of all parties concerned to this free testing session.
 I also understand that if I have a disability I may apply for accommodations by contacting the Testing Coordinator for further instructions.
 I understand that no cell phones or other electronic devices are allowed in the testing room.
 I understand that I may not discuss practice test or TASC test items with anyone, including my teacher or family members. I
understand that discussing test items may result in the invalidation of my test.
Signature of TASC Candidate: ________________________________________________ Date: ___________
ATTACH A COPY OF CURRENT & VALID STATE OR FEDERAL ISSUED ID TO THIS FORM
ID MUST BE PRESENTED DURING EACH TESTING SESSION.
*TASC candidates sixteen (16) years of age placed in an OIEP facility, Option Pathway, Mountaineer Challenge Academy or Job Corps may
take the TASC tests without an approved waiver from the WVDE. Nevertheless, the status of the sixteen (16) year old during the school
term must follow the guidelines set forth by the West Virginia Legislature, which means a sixteen (16) year old may not drop out of school.