Assessment Center: Test Accommodation(s) Request Form

I have previously been granted special testing accommodations with Brazosport College:*

YesNo
Student Information
BCID number:*
Date of Birth*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Email*
The e-mail address for your BC Student email account is your username@brazosport.edu
Daytime Phone Number*
Evening Phone Number
Test Information
Test I am requesting accommodations for:

TSIA2HESICredit by ExamCLEPOther
If TSIA2, please indicate the subjects you will be taking.

ELAR (Reading & Writing)MathRetest Essay Only (Retesting only available once deemed College-Ready via the TSIA 2.0 ELAR multiple-choice exam)Retest ELAR Multiple-Choice Only (No Essay, Retesting only available once deemed College-Ready via the TSI/TSIA 2.0 Essay)
List the specific testing accommodation(s) requested:*

Additional TimeAllow extra breaks as needed for food and/or medicationAllow medical device(s) in test roomOral (Read to Student)Test in private areaTest each subject individuallyUse Color Overlays (Student must provide.)Use of Green Overlay (Student must provide.)Voice-to-Text SoftwareOther
If any or all special accommodations I am requesting are denied, I would like to be registered under standard conditions.*

YesNo
Request a Test Date

Please provide two (2) dates and the time you would like to schedule your accommodated test. Please keep in mind that the system will limit your requested test date to at least 5 business days from today. Once you've submitted this form, you should receive an update from the Disability Counselor within 3 - 5 business days.
Option 1: Requested Test date/time:
Option 2: Requested Test date/time:
ELAR: Requested Test date/time:
Math: Requested Test date/time:
Retest Essay Only: Requested Test date/time:
Retest ELAR Multiple-Choice Only: Requested Test date/time:
Option 1: Requested Test date/time: *

MonthDayYear
DateHourMinutesAM/PM Option
ELAR Test Date:
Math Test Date:
Retest Essay Only Test Date:
Retest ELAR Multiple-Choice Only Test Date:
Student Certification*

By checking this box, I certify that I am the person whose name and address appear on this form. I am submitting, together with this completed Testing Accommodations Request form, any required documentation as requested by the Counseling and Testing department. I understand and agree that the special accommodations I have requested herein will be given due consideration. If, and to the extent that, any such request is granted, I understand that I will be taking the test under special conditions.
Print Name
Signature

Clear
Should be Empty:

Student Information

Test Information

Request a Test Date