Test Proctoring Request Form

Thank you for using the Study Skills Center.

Semester
Student's Name: Student's Name: First Last
Instructor's Name: Instructor's Name: First Last
Course:
Test Name:
Test Date Test Date / MM / DD YYYY
Test Time Test Time : HH MM AM/PM

If you would like to set up your student's test time please fill out the time, or if you prefer the student to schedule their own time please have them schedule it at (760) 355-6390
Date test should be completed by: Date test should be completed by: / MM / DD YYYY
Length of time student is allowed Length of time student is allowed : HH MM
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Please answer the following questions:
Please answer the following questions:	ALLOWED	NOT ALLOWED
Open Book	Open BookALLOWED	Open BookNOT ALLOWED
Notes	NotesALLOWED	NotesNOT ALLOWED
Dictionary	DictionaryALLOWED	DictionaryNOT ALLOWED
Calculator	CalculatorALLOWED	CalculatorNOT ALLOWED

Additional Instructions:
Additional Instructions:	YES	NO
Save scratch paper	Save scratch paperYES	Save scratch paperNO
Exam will be picked up at Study Skills Center	Exam will be picked up at Study Skills CenterYES	Exam will be picked up at Study Skills CenterNO