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California State University, Long Beach
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Faculty Handbook

Appendix D: Alternative Testing Accommodations Agreement Form


Instructor: _______________________________________________

Course: ______________ Day: _______________ Time: _____________________ Room: ____

Student: _________________________________________________

ALTERNATIVE TESTING LOCATION
Disabled Student Services (DSS)
BH- 270C x55401

THE FOLLOWING WILL BE PROVIDED TO THIS STUDENT: -(All tests are monitored)

_____ Proctor (reader/writer) _____ Computer
_____ Extended Time _____ 1 1/2 Time _____ 2 Time _____ 2 1/2 Time

PLEASE CHECK WHAT IS PERMISSIBLE DURING THE EXAM TO ACCOMMODATE THIS STUDENT:

______ Scratch Paper ______ Dictionary _____ Open Notes
______ Open Book ______ Thesaurus _____ Calculator
Other: __________________________________________________________________

PLEASE CHECK THE MOST APPROPRIATE METHOD FOR PICK-UP OF YOUR EXAM:

1. _____ Student may pick-up exam in a sealed envelope and deliver it to the Alternative Test Location.
2. _____ (faculty/designee) will deliver the exam to DSS (BH - 270C)
3. _____ request that the exam be picked up by DSS at
_______________________________________
Location/Date/Time

PLEASE CHECK THE MOST APPROPRIATE METHOD FOR THE RETURN OF YOUR EXAM:

1. _____ Student may return exam in a sealed envelope to the Department Office.
2. _____ (faculty/designee) will pick up the exam at DSS (BH - 270C).
3. _____ Please return exam to (Location) ___________________________________________________________
(DSS will do its best to deliver the exam in a timely manner)

Professor's Signature _____________________________________________________________________________

Extension _____________________________________________________ Office Room Number _______________

Student's Signature ______________________________________________________________ Date ____________

< Appendix C: Alternative Testing Accommodations Cover Letter | Faculty Handbook Table of Contents | Appendix E: Complaint Procedure >