Exam Certification Cover Sheet

Proctor Certification (required):

I affirm that I am an authorized proctor and that I am not a friend, relative, coworker, or subordinate of the person taking this exam. I certify that the enclosed exam has been administered in the manner described in this Exam Certification Cover Sheet and was completed and collected in the time period specified. I will return the exam directly to the instructor as stated below.

The exam was given on:Date (mm/dd/yy): Start Time: End Time:

Proctor Name (please print): Proctor Signature:

I further certify that I have reviewed the student’s ID (acceptable IDs are driver’s license or passport) and affirm that the person who took this exam is the enrolled student.

Student Name (please print): Student Signature:

Proctor Instructions:

  • Proctors only (not the student) must return this certification sheet and quiz/exam directly to the person and in the manner specified below.
  • All quizzes/exams must be proctored (except take-home exams). Proctors are not expected to administer exams outside normal working hours. However, the test should be given as close to the stated exam date as possible. If this cannot be accomplished, the student must make alternate arrangements with the instructor prior to the exam date. Contact the instructor if you have any questions about administering or returning the exam.
  • Keep a copy of the exam before sending. Be sure that the student’s name and email address is written on the exam itself. Follow the return instructions below.

Instructor Complete the Following:

Instructor:

Course Name and Number:

Deadline / Exam Date (date/range of dates when distance students should take exam):
Exam Return Date: Must be received by: Must be postmarked by:
Comments:
Format / Type:QuizMidterm Final Other
Format: Open book/notesClosed book/notes Take Home
Other
Time allotted for exam: (hours/minutes)
Return / Return this certification and exam to the instructor/TA using the instructions below. Do not send to the Graduate School office.
USPS Mail Special Delivery Address (FedEx, DHL, etc.)
Instructor NameInstructor Name
University of Colorado BoulderUniversity of Colorado Boulder
Dept Name Dept Name
UCB1111 Engineering Dr, Room
Boulder, CO 80309Boulder, CO 80309-
Enclosed: Exam for (student name)Enclosed: Exam for (student name)
Fax # (if permitted):Instructor phone #(for questions):
Email (if permitted):

Revised 9/29/2016