Make up test request form fillable

OFFICE USE ONLY
Received by:

MonthDayYear
Proctor Initials:
Log Number:
Make-up Testing Request for KCC Testing Center
Accommodation requested:

Extended timeScribeNoneTest Reader
If accommodations are requested, the test must be delivered to the testing center no less than 3 business days in advance to prepare for audio and scribe accommodation. For example, for a test needing to be taken on a Monday, the testing center would need to receive the test request and test no later than 8am the Wednesday prior.

If no accommodations are necessary, the test must be delivered to the testing center no less than 2 business days prior to the due date for the test to be completed by.
Student Name*

First NameLast Name
Course no.*
Test/Title Name*
Student ID (7 Digits):*
Date*

MonthDayYear
Date
Instructor*

First NameLast Name
Email *
example@example.com
Phone Number*
Please enter a valid phone number.
Deliver to:*

W102
Needs to be completed by*

MonthDayYear
Date
Length of time allowed in classroom*
Extended time on exams

YesNo
Amount:

50%DoubleOther
Enter extended amount of time
Mark Appropriate Boxes

Notes allowedCalculator allowedOpen BookUse of dictionaryBreaksUse Scantron SheetAnswers directly on testMay write on testScratch Paper
Online Verification-Required
Is this test delivered through the Online Learning Management System?*

YesNo
I have verified online settings for this test's availability to the student(s)(Published, Available From and Until dates, attempts remaining):

Yes
Should the test not be available due to an online setting, I consent to online help staff modifying the settings as necessary to allow access

YesNo
ACCESS CODE for online test (if one was used):
If online help staff modifies a setting in your course, it wil be documented and you will be contacted.
Details on above checklist or additional instructions
File Upload

Cancelof
OFFICE USE ONLY
Expired returned on:

MonthDayYear
Date
Date taken:

MonthDayYear
Date
Proctor
Seated at
Test start time
Maximum end time
Actual end time
Completed email sent date:

MonthDayYear
Date
* EXPIRED TEST MAY NOT BE GRADED BY INSTRUCTOR
Student Signature

Clear
Date

MonthDayYear
Date
Student advised testing center closes at:
Initials
Received by
Date

MonthDayYear
Date
Should be Empty:

OFFICE USE ONLY

Make-up Testing Request for KCC Testing Center

Online Verification-Required

OFFICE USE ONLY

* EXPIRED TEST MAY NOT BE GRADED BY INSTRUCTOR