Proctored Testing Request Form
Student Name
*
First Name
Last Name
Type of Request
*
Make-up
Accommodated
Placement Exam (Math or Comp)
Credit By Exam
CLEP
Other
Other
Course Number
*
(biol 101, chem 102, math 202, etc)
Exam Title
*
(exam 1, midterm, final, etc)
Exam Type
*
Choose one
Paper & Pencil
Web-Based Computer
Non-Web-Based Computer
In-Class Testing Date
*
/
Month
/
Day
Year
Date
In-Class Time Allotted
*
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
Exam Due Date
*
/
Month
/
Day
Year
Date
Exam Supply Method
*
Choose one
File Upload
Hand Deliver
Embedded in Course Shell
Standard Math Placement Exam
Standard Composition Placement Exam
Standard CLEP Exam
This is how you plan to provide the exam to the ARC.
Browse Files
Cancel
of
Moodle Password (if required, or N/A)
Password for proctor to unlock exam for student
Exam Return Method
*
Choose one
Hold for pick up
Scan & email
Embedded in Course Shell
This is how you would like the ARC to return the completed exam to you.
Instructor Name
*
First Name
Last Name
Instructor Daytime Phone
*
Instructor Email
*
example@friends.edu
Which placement exam(s) does the student need to take?
*
English/Composition
Math
Both
For what subject or course is the student wanting to take a CLEP or Credit by Exam test?
*
What is the time frame for taking the placement/CLEP/Credit by exam(s) for the student (e.g. this week, 2-3 weeks, this month, etc.)?
*
What is the Student N number?
*
Student Email
*
example@example.com
Student Phone Number
*
-
Area Code
Phone Number
Who is the student's advisor? (Who all needs to know the results of the exam?)
*
Conditions
*
None
(calculator, dictionary, notes, open book, etc.)
Notes - Is there anything else we need to know?
Save
Submit
Should be Empty: