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Exam Proctor Form

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					                                                                CONTROL NUMBER __________
                                                        (Student Success Center Use Only)

                         EXAM PROCTOR REQUEST
DIRECTIONS:
1. Complete this form and return it with the exam to Student Support Services, SWRZ 38.
2. Have the student contact the Student Success Center at ext. 5326 to schedule an
   appointment.

Student’s Name:

Instructor:                                 Course Name & Number:

The instructor can be contacted at:


PROCTORING INSTRUCTIONS:

Open book:       Yes       No

Open notes:       Yes       No

Note Card(s):      Yes         No     Note Card Requirements:

Calculator:     Yes       No

Scantron required:       Yes         No (Please provide Scantron if required)

Time Limit (do not include extended time):                              (Must be filled in)

The exam must be completed by the following date:

Other Instructions:


HOW WILL THE EXAM BE RETURNED TO THE INSTRUCTOR?

     Hold for pickup by instructor           Campus Mail             Returned by student

Instructor’s Signature:

STUDENT SUCCESS CENTER USE ONLY
Date Exam Received: __________________        Date Proctored: ________________________
Time Exam Started-Initials: ______________    Time Exam Finished-Initials: ______________
Exam Returned Via: ___________________        Date Returned-Initials: ___________________

				
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