Ivy Tech Community College of Indiana
DISTANCE LEARNING PROCTORING FORM
Routing Information (To be completed by Instructor or Regional Designee) ORIGINATING SITE: TESTING SITE: Name: Ivy Tech Community College Name: Department: Testing Center Department: Address: 8000 South Education Drive Address: City: Terre Haute State: IN Zip: 47802 City: State: Zip: Phone: 800-377-4882 ext. 2258, 2447, or 2404 Phone: Fax: Fax: Email: assessment@goivytech.net Email: Exam Information (To be completed by Instructor) Student Information Student Name: ADA Approved Accommodations (please specify):
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Instructor Information Instructor Name: Campus: Address: Phone: Test Information Course Number: Course Name: Number of questions: Date Exam Available: Deadline Extensions: Time Limit: ½ hour
Email: Region: City: Alternate Phone:
State:
Zip:
Course Section: Exam Name: Voucher Number (if applicable): Deadline for Completion: Past/Pull Due: None Automatic – no permission necessary Student must contact instructor 1 hour 1 ½ hours 2 hours 2 ½ hours 3 hour Other:
Online Exam Access Blackboard Exam location within Blackboard (required for Blackboard tests): Non-Blackboard Supply URL (required for non Blackboard web based tests): Supply Password (case sensitive) if required: Required Materials/Equipment Dictionary Calculator: Notes: Other: Standard None Printer Thesaurus Scientific 1-3x5 Notecard Software (specify): Scratch paper Graphing 1-5x7 Notecard 1-8½ x 11 Sheet Textbook Headphones
Permitted Testing Materials: Check all that apply. All scratch paper and notes used for testing will be collected.
Instructor-Provided Materials Additional materials (specialized vendor texts, blueprints, trade-specific calculators, measurement devices, CDs, scanning sheets, etc.) must be provided by the instructor with a paid return envelope. Instructors must make prior arrangements with the testing center for any materials or equipment not provided by instructor or student. Return Instructions Proctors should return scratch paper, notes, and instructor materials to the person listed at the top of this form via: No need to return Intra-campus mail U.S. Mail specify Originating site address OR Instructor address Proctor Information (To be completed by the Proctor) Identification Verified: YES Date test received by proctor: Comments:
Revised August 2007
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Proctor's signature: ____________________________ Date test administered to student: Date materials returned: