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DISABILITY SERVICES

Test Request Form

Name:

Phone Number:

Class (like Soc 111):

Instructor:

Instructor's Email (from the course syllabus):

Is this an ONLINE test or quiz?
Yes No

Date to take the test (Please give 3 days' notice; this does NOT include Saturday & Sunday):
  (Month/Day/Year -- ex: 02/16/17)

Start time for test/quiz:

Will the class take the test/quiz on the same date you've requested above?
Yes No

Accommodations Needed for this Test/ Check all that apply!

Extended Time

Proctor (Reader/Writer)

Braille

Enlarged Test — Font Size Needed

Private Room

Computer

Visual Tech

Color Paper

Your E-mail Address: