Request for Individualized Testing Accommodations (RITA) @ UH Sugar Land campus
Section 1: To be filled out by student
Student Name______
Phone Number Email
Course Name______Subject & Number______
Instructor’s Name______
Requested Accommodations:
Based on my Student Accommodation Form (SAF), I request the following accommodations for exams in this course. (Please check all that apply.):
____Extended (up to double) testing time – Total time______Use of computer (without internet access)
____Scribe (for Scantron or typist) (Please circle one)
____Other ______
Student’s Signature ______Date ______
Section 2: To be filled out by instructor
The student named above has presented me with his/her Student Accommodations Form (SAF). I agree to the requested exam accommodations as set forth in Section 1. Exams taken at the Sugar Land campus will be administered by either the instructor ora Proctor (5 days notice required).The student also has the option to go to CSD office at University of Houston central campus to take the exam.
Note: If start-times are negotiable (within Mon.-Fri.: 8 am to 5 pm; Fall & Spring 8 a.m. to 7 p.m. Mon. & Tues.) place an (N) in the space designated.
STUDENT must return form to GB 119 at Sugar Land campus for submission to UH CSD Department for approval. For questions, contact UH CSD @ 713-743 5400
Form revised: 2015-10-19
1. Date______Start Time______End Time______
2. Date______Start Time______End Time______
3. Date______Start Time______End Time______
4. Date______Start Time______End Time______
5. Date______Start Time______End Time______
6. Date______Start Time______End Time______
STUDENT must return form to GB 119 at Sugar Land campus for submission to UH CSD Department for approval. For questions, contact UH CSD @ 713-743 5400
Form revised: 2015-10-19
Location of exam: Room # ______(If the room is not available, another will be reserved based on availability)
Will a Proctor be needed for test? Y / N
(5 day minimum notice required for Proctor; Proctor available onlyMon.-Fri. 8 am to 5 pm; Fall & Spring 8 a.m. to 7 p.m. Mon. & Tues.)
Exam delivery options (exam must be delivered at least 48 hours prior to exam)
____ Instructor will email exam to
____ Instructor will drop off exam to George Building room 119
Additional Instructions:
Student may use the following during this exam:
____ Calculator ____ Book ____Notes ____Computer ____Other:______
Special Notes for Proctor to follow during exam:
______
______
Note: Only one Proctor will be provided for the exam based on availability. If a Proctor is not available, you will be notified at least 48 hours prior to the exam. At least 48 hours notice is required for changes to exam schedule if a Proctor was requested. Notify of changes.
Instructor Name ______
Instructor Signature______Date______
Contact Person ______Phone______Email______
STUDENT must return form to GB 119 at Sugar Land campus for submission to UH CSD Department for approval. For questions, contact UH CSD @ 713-743 5400
Form revised: 2015-10-19