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Instructor Test Entry Form – Disability ServicesComplete this form and attach it to your test.Bring form and test to the Disability Services (DS) office in Terrell, room 219 (TE-219) at least one business day prior to the first active date of the test (as you indicate below). DS will log the test in and give it a Test Document Number.Tests received in DS on the same day as the first active date may not be available to the student until the following business day.Your test must be active for at least one full day.Failure to submit the test before the scheduled appointment will result in an appointment reschedule. Instructor Name: _______________________________________________________Phone Number or 4-digit Extension: ________________________________________Email address: _________________________________________________________Student Name: _________________________________________________________Course: Prefix: ____________________ Number: _________________ Section: ____________Test Title/Identifier (Chapter, #, etc.): _________________________________________________Test Active Dates: From ______________________ thru ________________________Amount of time allotted for all other students in class: Hrs: __________ min: ________How do you want to receive the completed test (choose one option):I will pick it up from the Disability Services in TE-219I want DS to scan and email it to me (original to be shredded upon confirmation of receipt)I want DS to send it back to me by campus mail (DISCOURAGED – compromises security of the test)Student will record answers on (check all that apply): Test Hard Copy Scantron sheet (must be provided by instructor) Instructor scored answer sheet Computer (Blackboard, Moodle, etc.) Other (please specify) ________________________________________Student may use (check all that apply): Scratch Paper Dictionary (All students) Non-programmable Calculator Dictionary (International Students) Programmable Calculator Textbook(s) Notes (check all the below that apply): Paper Power Points Online Other (please specify) ____________________________TO BE COMPLETED BY DS STAFF: Test Document Number _________________ ................
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