Test Compromise Information Form - ICCB

ROEs ONLYRequest for Access (or Removal of Access) To High School Equivalency Records 2002-Current/ Computer-Based Constitution TestRegional Office of EducationName of Regional Office of Education: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP: FORMTEXT ?????If you are a Pearson VUE Testing Center, please provide your PVTC #: FORMTEXT ?????Regional Superintendent Name: FORMTEXT ?????Regional Superintendent Phone Number: FORMTEXT ?????Regional Superintendent Email Address: FORMTEXT ?????I recommend that the following person be given access to:(select all systems that apply) FORMCHECKBOX ILHSE Database FORMCHECKBOX Computer-based Constitution Test AdministrationUser Name: FORMTEXT ?????User Title: FORMTEXT ?????User Phone Number: FORMTEXT ?????User Email Address: FORMTEXT ?????Current Access (Please indicate if this person already has access to any of the systems listed) FORMCHECKBOX ILHSE DatabaseID Used: FORMTEXT ????? FORMCHECKBOX CBT Constitution Test AdministrationID Used: FORMTEXT ?????Please REMOVE access for the following individual (select all systems that apply): FORMCHECKBOX GED Archive Database FORMCHECKBOX ILHSE Database FORMCHECKBOX Computer-based Constitution Test AdministrationUser Name: FORMTEXT ?????User Email Address: FORMTEXT ?????ApprovalI understand that by granting access to the these systems, I am allowing the above named person to access confidential and sensitive, personally-identifiable test-taker information and that I accept full responsibility for ensuring that this information will be kept confidential and will not be used inappropriately by said person. FORMTEXT ?????Regional Superintendent’s SignatureDate ................
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