ESL/Francisation Request for Extra Time to Write a Diploma

Examination 2012–2013

ALBERTA STUDENT
NUMBER (ASN)
SURNAME
LEGAL FIRST AND
MIDDLE NAMES
BIRTH DATE / Year / Month / Day / SEX / M–Male
F–Female / TELEPHONE

(e.g., 95 Jul 20)

PERMANENT
ADDRESS / Apt/Street/Ave/P.O. Box/Route
Village/Town/City
Province / Postal Code

1.  Examination administration session for which this request applies (use a separate application form for each session)

November 2012; deadline for application: October 1, 2012 June 2013; deadline for application: April 12, 2013

January 2013; deadline for application: November 5, 2012 August 2013; deadline for application: July 16, 2013

April 2013; deadline for application: February 27, 2013

2.  Diploma examinations for which the accommodation of extra time is being requested


Biology 30
Exam
English French
Extra Time / Exam
English French
extra-time / Exam
English French / Exam
English French / Exam
English French / Exam
English French

3.  Language Proficiency Test Scores:

Language Proficiency Test #1:

(Name and test form used)

Date test was administered: Duration of assessment (hr/min):

Administrator (name and title):

Test results and analysis:

Section:
Section:
Section: / Raw Score:
Raw Score:
Raw Score: / Grade equivalency
Grade equivalency
Grade equivalency

Language Proficiency Test #2 [If applicable]:

(Name and test form used)

Date test was administered: Duration of assessment (hr/min):

Administrator (name and title):

Test results and analysis:

Section:
Section:
Section: / Raw Score:
Raw Score:
Raw Score: / Grade equivalency
Grade equivalency
Grade equivalency

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Student Name: Student ASN:


4.  Student’s education/language background

(country of origin, date of arrival in Canada [if applicable], language(s) spoken in the home, previous educational experience, language

proficiency on arrival, etc.)


5.  History of use of the requested extra time accommodation for examination writing purposes

For each examination course for which the extra time accommodation is intended, complete the following:

Diploma Examination Course:
I attest that the information provided below is true:
Teacher’s name Teacher’s signature Date
Exam administration session(s) for this course when extra time was permitted and used by the student [exam name(s) and date(s) administered]:
Diploma Examination Course:
I attest that the information provided below is true:
Teacher’s name Teacher’s signature Date
Exam administration session(s) for this course when extra time was permitted and used by the student. Include exam name(s) and date(s) administered:
Diploma Examination Course:
I attest that the information provided below is true:
Teacher’s name Teacher’s signature Date
Exam administration session(s) for this course when extra time was permitted and used by the student. . Include exam name(s) and date(s) administered:
Diploma Examination Course:
I attest that the information provided below is true:
Teacher’s name Teache’sr signature Date
Exam administration session(s) for this course when extra time was permitted and used by the student. Include exam name(s) and date(s) administered:

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Student Name: Student ASN:

6.  Writing centre and school information

• Writing centre where the diploma examination(s) will be written.

Writing Centre Name CBe-learn School Code: 1064

• School where the course(s) are or were taken

School Name CBe-learn School Code: 1064

7.  Student and parent/guardian declaration

I was permitted and regularly used extra time as an accommodation when writing exams for the course(s) for which the accommodation is currently being requested.

The information provided on this application form is true, accurate, and complete.

Signature of Student (typed signatures will not be accepted) Date Email address Date

Signature of Parent or Guardian (if student is under 18 years of age)


8.  Application Process Manager Sign-off

To be completed by the principal of the Alberta high school the student is currently attending, or his/her delegate.

School Code 1064 School Name CBe-learn

Name School Telephone 403-777-7971

Please Print Area Code Extension #

E-mail Address Fax Number 403-777-7270

Area Code

Signature Date

Failure to submit a complete application and appropriate documentation by the deadline specified on the first page of this form will result in the request being denied.

The personal information collected on this form is being collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act, and will be used to administer and process the writing and/or rewriting of diploma examination(s). It will be treated in accordance with the privacy protection provision of Part 2 of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection of this information, contact the Director, Exam Administration, at 780-427-0010 (to be connected toll-free within Alberta, first dial 780-310-0000).

Upon receiving the application at CBe-learn we will review, complete and submit it to Alberta Education:

Alberta Education, Special Cases and Accommodations

44 Capital Blvd. E-mail:

10044 – 108 Street Phone: (780) 427-0010 Fax: (780) 422-4889

Edmonton AB T5J 5E6 To be connected toll-free within Alberta, dial 310-0000

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Alberta Education – ESL/Francisation Request for Extra Time to Write a Diploma Examination 2012–2013 August 2012