Bloomfield College Services for Students with Disabilities
*Must be submitted to OSD 7 days prior to the Exam*
|Part I: To be completed by the student |
|Student’s Name:______________________ Phone:_________________ |
|Date of test (s) for the class:____________________________________ |
|Start time/end time for class taking exam:__________ to _______________ |
|I need: Proctor_______ Scribe________ Technology_______ Quiet space_______ |
|****** Part II: To be completed by the professor******* |
|Instructor’s Name:_______________________ Course:________________ |
|Instructor’s extension #:___________(where you can be reached during the exam) |
|Instructor’s email address:____________________________________ |
|Test format: ______ essay _____ multi choice _____ true/false ______ fill in |
|_____ short answer Test to be taken no later than:_____________ |
|Exam Delivery Instructions The exam will be: |
|______ Delivered by the instructor to OSD (Learning Resource Center ) |
|______ Sent by email (address below) |
|______ Sent by fax (973.748.7751) |
|Return Delivery Instructions The completed exam will be: |
|______ Delivered by OSD to the instructor’s office/mailbox (location:____________) |
|______ Picked up by the instructor from OSD (Date and Time:___________) |
|______ Returned by fax: ____________________ |
|______ Returned by email: ________________________ Special Instructions :Open book Open notes ,Formula card ,prewriting |
|,Internet access or as listed below: |
|___________________________________________________________________________________________________________________________________|
|___________________________________________________________________________________________ |
|Professor’s signature:__________________________________________________ |
|To be completed by OSD staff |
|Accommodation provided:____________________________________________ |
|__________________________________________________________________ |
|Unusual details noted on the reverse side of this page |
|Date Exam given:______ Exam start time: _________ Exam end time:______________ |
|Comments:___________________________________________________________________ |
|____________________________________________________________________________ |
|TEST Copied______ Test sent_______ location given________ Computer terminal used ____ |
|Proctor:______________________________________ |
If you have any questions or concerns, please contact: Margaret Adams at ext. 1654
Or Margaret_Adams@bloomfield.edu (revised 3/10/11 MGA)
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