Appendix 1-C
Revised 09/2015
(Shaded areas are to be completed by Test
West Virginia TASC Form
Institutional Education
Coordinator or Examiner)
UUID: _________________________
Form: ___________
Date Tested: ___________________
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 TASC Examinee (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 
Math

Social Studies 
Writing 
Science 
UUID (TASC ID)
TASC Testing Information – To be completed by TASC test-taker
 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).
If you have tested before, name the state/s where you tested _______________________________.
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
OPT
Math 8 pts 
Math 470 pts 
Reading 9 pts 
Reading 470 pts 
Science 7 pts 
Science 470 pts 
Social Studies 9 pts 
Social Studies 470 pts 
Writing 13 pts 
Writing 470 pts 
Signature of Institutional Education WVAdultEd or Option 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. Should a cell phone or other electronic
device be found at my seat or on my person, the TASC test materials will be collected, my test scores will not be valid, and my
cell phone will be confiscated. I will be required to leave the testing center. I may not reschedule to test for a minimum of six
months and after the six months will need permission from the State TASC Administrator to test.
 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 Test Candidate: _______________________________________ Date: ___________
ATTACH A COPY OF CURRENT & VALID STATE OR FEDERAL ISSUED ID TO THIS FORM
ID MUST BE PRESENTED DURING EACH TESTING SESSION