Exam Restriction Request Form
Submit your request for exam restrictions, exemptions, or alternate arrangements.
Full Name
*
First Name
Last Name
Student ID Number
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Course Name and Code
*
Exam Name or Type (e.g., Midterm, Final, Quiz)
*
Please Select
Midterm
Final
Quiz
Other
Scheduled Exam Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Restriction Requested
*
Exemption from Exam
Alternate Exam Date/Time
Remote/Online Exam Option
Other (please specify)
Reason for Request
*
Please Select
Medical Reason
Personal Emergency
Religious Observance
Schedule Conflict
Other
Please provide details about your reason for the request
*
Upload Supporting Document(s) (e.g., medical certificate, official letter)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Have you previously submitted an exam restriction request for this course?
*
Yes
No
Preferred Outcome (if any)
Submit Request
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