Student Services

Accessibility Supports and Disability Services

______________________________________________________________________________

EXAM ACCOMMODATION REQUEST FORM

All forms are due at least 7-days prior to exam date. Incomplete forms will not be accepted.
TO BE COMPLETED BY STUDENT:
Date of Request: ___________________________________________

Student Name: _____________________________________________

Course ID: __________________________________________________

Date of Exam: ______________________________________________

Student ID: ______________________________

Instructor: ______________________________

Please check if: Extended time conflicts with another class, exam or work. If yes, discuss the conflict with
your instructor to determine an adjusted start time/date and have your instructor contact ASDS indicating
their approval for an adjustment.
Exam Accommodations Requested:

Extended time for exam (1.5 times) or specify: _____________ Distraction Free Area
Use of computer
Alternate Format Kurzweil RWG
Reader/Scribe
Other Accommodations; please specify: _________________________________________________________________
TO BE COMPLETED BY INSTRUCTOR:

Date of Exam: _________________________________________________

Exam Start Time: _____________________________________________

Exam End Time: ______________________________

Course ID: _____________________________________________________

Instructor: _____________________________________

Notes/Formula Sheet(s)

Textbooks/Manuals

Exam Specifications:

Calculator

Other _______________________________________

Additional instructions:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

Instructor Contact Information: _______________________________ Location during Exam: _______________________________

(If the student has questions during the exam please provide phone number or classroom location)

Delivery of Completed Exam: If this section is left blank, the exam will be forwarded to the instructor via Internal Mail.
Pick-up exam at ASDS
Send through internal mail
E-mail scanned copy of exam

I agree to have ASDS administer this exam for the above student on the date and time listed above with the
appropriate accommodations, and to send a copy of the exam at least two (2) days in advance.
________________________________________________________
Instructor Signature

_______________________________________________________
Date

ASDS STAFF USE ONLY

Exam Accommodation Form Received:
Name: ___________________________________________________

Date: __________________________________________________

Instructor contacted to Request Exam

Exam Received:

Date: __________________________________________________

Instructor: _____________________________________________

Date: __________________________________________________

Submitted at least 7-days prior to Exam? Yes No

If No, Reason: ____________________________________

Required Exam Materials: ________________________________________________________________________________________

Proctor Log
Name of Proctor: ______________________________________________
Scheduled Exam Start Time: _________________________________

Building & Room: __________________________

Actual Exam Start Time: _______________________________ Expected End Time: ____________________________________

Actual Exam End Time: ________________________________
Computer Use: Yes No

Breaks:

Computer #: ______________________

(1) Time Out: ___________

(2) Time Out: ___________

Time In: ____________

Time In: ____________

Comments:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Proctor Signature: ___________________________________________________________
Exam Completion Information:
Name: _______________________________________________
Delivered:

Internal Mail

Date: _________________________________________________

Picked-up

E-mail

PLEASE SUBMIT COMPLETED EXAM ACCOMMODATION REQUEST FORMS TO:

Accessibility Supports and Disability Services Student Services
H103, 10726 106 Ave, Grande Prairie, AB
Phone: (780) 539-2944 or 1-888-539-4772 Fax: (780) 539-2888