New York City Westchester
THE OFFICE OF DISABILITY SERVICES
NEW YORK CAMPUS
NEW YORK CITY WESTCHESTER
8TH FLOOR
NEW YORK CITY WESTCHESTER
NEW YORK, NY 10038
NEW YORK CITY WESTCHESTER
PHONE: (212) 346-1526
FAX: (914) 989-8047
NEW YORK CITY WESTCHESTER
THE OFFICE OF DISABILITY SERVICES
NEW YORK CAMPUS
156 WILLIAM STREET, 8TH FLOOR
NEW YORK, NY 10038
PHONE: (212) 346-1526
FAX: (914) 989-8047
TESTING ACCOMMODATIONS REQUEST FORM
Instructions: It is the student’s responsibility to return this form FULLY COMPLETED to the Office of Disability Services 10 days prior to the date of the exam. Arrangements for exams outside of scheduled exam hours will require approval by the Office of Disability Services.Exam hours for fall and spring: Monday, Wednesday, Friday 9-5; Tuesday, Thursday 9-7.
STUDENT INFORMATION - MUST BE COMPLETED BY STUDENT:Name: ______/ Pace E-mail:
Semester: ______/ Course Name & Number: ______/ Professor: ______
Class Exam Date: ______/ Class Exam Time: ______
Which of your approved accommodations do you require for this exam? (Please circle each.)
Extended Time / Calculator / Computer / Reader / Scribe / Other: ______
Phone Number ______Preferred Method of Contact (Circle): Phone or E-mail
Student Signature: ______
FOR EXAM CONFLICTS:
Students and Professors must complete this section TOGETHER if student’s schedule conflicts with the exam period. Arrangements will be confirmed by ODS Staff. Exam hours are Monday, Wednesday, Friday 9-5; Tuesday, Thursday 9-7 for the fall and spring semesters and Monday-Friday, 9-5, for the summer semesters.
Alternative Date: ______/ Alternative Time: ______
Student Signature: ______/ Professor Signature: ______
INSTRUCTOR INFORMATION - MUST BE COMPLETED BY PROFESSOR:
Amount of time class receives for exam (ODS will increase accordingly): ______
All students are allowed the use of the following:
□IF NO AIDS ARE ALLOWED CHECK HERE
□Open Book, Class notes, Textbook: ______
□Calculator (circle): Graphing / Scientific (non-graphing) / 4 Function
□Computer (circle): With Internet / Without Internet
□Formula Sheets, Tables (please specify): ______
□Other: ______
Email: ______/ Phone: ______
How can we contact you if the student has a question during the exam? ______
How will ODS receive your exam? / Return information for exam:
□Professor will drop off: ______/ □Instructor will pick up exam at ODS
□Exam will be emailed to Accommodations Coordinator () / □ODS will e-mail scanned copy of completed exam to: ______
□Exam will be faxed to ODS at (914) 989-8047 / □Exam will be faxed to: ______
□Other: ______/ □Other: ______
Professor Signature: ______
ODS will administer this exam to the student on the agreed upon time and date.Exams must conclude by 5 pm Monday, Wednesday, Friday or 7 pm Tuesday, Thursday for fall and spring. Please submit the exam 24 hours before the test time.
ODS STAFF USE ONLY:
□Schedule Exam □ Confirm Exam □ Receive Exam
NEW YORK CITY WESTCHESTER
THE OFFICE OF DISABILITY SERVICES
NEW YORK CAMPUS
156 WILLIAM STREET, 8TH FLOOR
NEW YORK, NY 10038
PHONE: (212) 346-1526
FAX: (914) 989-8047
ODS STAFF USE ONLYProctor Log:
Name of Proctor: ______/ Date: ______
Amount of Time Student Receives for Exam: ______/ Room: ______
Scheduled Start Time: ______/ Scheduled End Time: ______
Actual Start Time: ______/ Actual End Time: ______
Computer Used: Yes______No______/ Computer #: ______
Breaks:
Time Out ______Time Return ______Reason For Break: ______
Time Out ______Time Return ______Reason For Break: ______
If a student takes more than 2 breaks, please alert a member of the ODS staff.
Notes:
______
______
______
Proctor Signature: ______
After Exam:
□Copy exam for ODS files
□Prepare exam for delivery
□Professor pick up
□Scan to professor and
□Student Delivery
□Other: ______
□Send Delivery Confirmation
□File copy of exam in ODS files
Completed by: ______/ Date: ______
NEW YORK CITY WESTCHESTER