The University of Northern Iowa Examination Services

The University of Northern Iowa Examination Services

In association with Student Disability Services

EXAM ACCOMMODATION REQUEST FORM

Exams with accommodations are encouraged to be made and directed by the class instructor. Instructors may utilize their own department rooms to fulfill the needed accommodations. If instructors are unable to make arrangements, Examination Serviceswill be able to administer the exam with a one week notice. Testing hours are currently 9:00 a.m. – 4.00 p.m., Monday – Friday. To schedule exams, please complete the following and email the form r deliver to the Academic Learning Center, Room 007 ITTC Bldg. (Please also carbon copy this form to the student) If you have questions, please contact Examination Services at (319) 273-6023.

STUDENT INFORMATION

Student Name: ______Student Phone: ______

Student Email: ______Student ID: ______

COURSE INFORMATION

Couse Name: ______Couse Number: ______

Instructor Name: ______Department: ______

Instructor Phone: ______Instructor Email: ______

EXAM INFORMATION

Please complete this form for all exams you are requesting to have administered by Examination Services. Depending on scheduling and availability, Examination Services may not be able to administer an exam on a specific day/time. If possible, Examination Services will work with the student and instructor to arrange an alternative date/time. Please let us know if you are flexible in allowing the student to schedule exams or re-scheduled missed exams without your final involvement.

Exam 1

Exam date requested: ______Howmuch time is allowed for the class to take the exam? ______hrs.______mins.

Exam 2

Exam date requested: ______Howmuch time is allowed for the class to take the exam? ______hrs. ______mins.

Exam 3

Exam date requested: ______Howmuch time is allowed for the class to take the exam? ______hrs.______mins.

Exam 4

Exam date requested: ______Howmuch time is allowed for the class to take the exam? ______hrs. ______mins.

Final Exam

Exam date requested: ______Howmuch time is allowed for the class to take the exam? ______hrs. ______mins.

ADDITIONAL EXAM RESOURCES ALLOWED

_____Calculator_____Articles/Reading_____Course Packet_____Dictionary_____Formulas_____Internes access_____Notes _____Note cards _____Scratch paper _____Textbook _____NONE _____ Student is allowed to re-schedule missed exams _____ Exam Services must contact professor regarding missed exams for re-scheduling date and time. Other:______

DELIVERY OF THE EXAM TO EXAMINATION SERVICES (Select One)

IMPORTANT NOTE – Exam(s) must be received 48 Hours prior to scheduled test date.

_____Email (Word or PDF): _____ Delivered by Instructor to Academic Learning Center(48 Hours prior to scheduled test date)

COMPLETED EXAM(S) Returnedto Instructor (Select One)

_____ Email (PDF)_____ Picked up from Examination Services (by Instructor) or Alternate Name: ______

By signing this form, I acknowledge that I understand and agree to follow the policies and procedures set forth by Examination Services for the use of their facility in administering exam accommodations.

Chapter 22 Code of Iowa: This information is requested to provide examination accommodations. Only directory information may be released to third parties. All items are required and therefore incomplete forms may not be processed.

Instructor Signature: ______Date: ______.