Student Affairs Proctor Request 2

Faculty, please complete the following form to request a proctor for an upcoming student exam. The Office of Student Affairs will do everything to honor this request; however, we cannot guarantee a proctor will be available for the requested time. Please submit your request at least seven days in advance of the exam. For requests sooner than seven days, submit the form and contact James.Dyksen@jefferson.edu as soon as possible.

1. Names of Students: *This question is required.

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Instructor’s Name: *This question is required.

Instructor’s Name:

2. Instructor's Email Address: *This question is required. This question requires a valid email address.

Instructor's Email Address:

3. Course Name/ #: *This question is required.

Course Name/ #:

4. Date of Regularly Scheduled Exam: *This question is required. This question requires a valid date format of MM/DD/YYYY.

Date of Regularly Scheduled Exam: calendar

5. Start/End Time of Regularly Scheduled Exam: *This question is required.

Start/End Time of Regularly Scheduled Exam:
(not the time with accommodation)

Is the student able to start the exam earlier than the regularly scheduled time or can the exam be scheduled at an alternative date and/or time?
(Please consider course schedule):

6. Is the student able to start the exam earlier than the regularly scheduled time or can the exam be scheduled at an alternative date and/or time? (Please consider course schedule): *This question is required.

7. Proposed Start and End Time with Accommodation *This question is required.

Proposed Start and End Time with Accommodation

8. Instructor Campus Phone Number: *This question is required.

Instructor Campus Phone Number:

9. Instructor Cell Phone Number: *This question is required.

Instructor Cell Phone Number:

Additional Contact Numbers for individual(s) who will be available to answer questions during the exam, if available.

11. Additional Contacts 1

Name:
Contact:

12. Additional Contacts 2

Name:
Contact:

13. Additional Contacts 3

Name:
Contact:

14. Exam Materials/Format:

Please identify any and all additional items allowed in the exam room (ex. calculator; scratch paper; open text,etc.) Any items not listed here will not be allowed in the exam room

15. Please identify any and all additional items allowed in the exam room (ex. calculator; scratch paper; open text,etc.) Any items not listed here will not be allowed in the exam room

Any Additional Comments or Special Instructions for the Exam:

16. Any Additional Comments or Special Instructions for the Exam: