Proctored Exam Integrity Form
Please complete this form to verify exam session integrity and compliance with exam protocols.
Student Full Name
*
First Name
Last Name
Student Email Address
*
example@example.com
Exam Name or Course Title
*
Exam Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Proctor's Full Name
*
First Name
Last Name
Location of Exam (e.g., Home, Exam Center)
*
Confirm the Following Exam Environment Integrity Checks
*
Rows
Confirmed
Not Confirmed
Not Applicable
No unauthorized materials are present
1
2
3
No other persons are in the room
4
5
6
Device camera and microphone are functioning
7
8
9
Screen sharing is enabled for the proctor
10
11
12
Internet connection is stable
13
14
15
Exam area is clear and visible
16
17
18
During the exam, did the student attempt to communicate with anyone else?
*
No, the student did not communicate with anyone.
Yes, the student attempted to communicate with someone.
Were there any technical issues or suspicious activities observed during the exam?
*
No issues observed
Yes, issues or suspicious activities were observed
Please provide details if any issues or suspicious activities were observed.
Signature of Student or Proctor
*
Submit Integrity Form
Submit Integrity Form
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