Student's name(s)
*
I allow DSS to administer this exam to any other DSS students enrolled in this course and approved for testing accommodations
*
Yes
No
Instructor's name:
*
Instructor's e-mail:
*
example@example.com
Course name and #:
*
Date your class is scheduled to take exam:
*
-
Month
-
Day
Year
Date Picker Icon
Is the exam Online? (Canvas or other online platform)
*
Yes
No
On what Online assessment platform is the exam located on?
*
Please Select
Canvas
Top Hat
KAPLAN [Nursing]
Other
What is the name of the exam as it appears on the platform (link name)?
*
Quiz 1
Time of class exam
*
Amount of time given to class:
*
Do you permit students to take exam at a time other than what is indicated above?
*
Yes
No
If "Yes", exam needs to be taken no earlier than:
*
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
and FINISH no later than:
*
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
If the student has questions during the exam, how may we contact you?
*
Scantron required?
Yes
No
Scantron type:
Red (200 answers)
Green (100 answers)
Blue (100 answers)
Calculator allowed?
Yes
No
Calculator type:
Graphing
Scientific
Basic
Any
Green Book required?
Yes
No
Notes allowed?
Yes
No
Please specify:
Notes must be submitted with exam?
Yes
No
Open book allowed?
Yes
No
Special Instructions (please be specific):
Please pick up the completed exams at the DSS Office located in Schulz 1014-A between the hours of 8:30 am - 4:30 pm. Thank you.
Select "Browse" button to attach file(s):
Acceptable file extensions: pdf, doc, docx, rtf, txt, odt, xls, xlsx, ppt, ppts, png, jpg, jpeg, bmp, gif, aac, mp3, wav, mp4, m4a, m4v, mpg, mpeg, flv, f4v, webm, mkv, avi, wmv, mov
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By submitting this form, I acknowledge that all the information has been approved by me and that I am aware of the testing guidelines that are enforced by DSS.
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