Student Alternate Testing Request Form Disability Support Services Please note that all requests must be submitted one week in advance. You should speak to your instructor to discuss a date and time for the exam before submitting this form. Please provide all information on this form and submit. You will receive a confirmation email. Submission of this form does not constitute confirmation of this appointment. Exam Proctoring Hours Fall and Spring Semesters Monday - Friday: 8:30 am to 4:30 pm Tuesday and Wednesday: 4:30 pm to 9:30 pm Summer Hours Monday - Friday: 8:30 am - 4:30 pm Student/Course Information Name* E-Mail Address* Phone* Course Title* Department* Please select ACT AMA ANT ARA ART ASL BIO BUS CHM CJS CMM CRW CSC ECO EDG EDL EDU ENG FIN FLL FRN GER GWS HON HRM HST IRL ITL LAT LAW MGT MIS MKT MTH MUS NRS NSG NSS OPM PAS PGS PHL PHS PHY PSC PSY REL SOC SPN STA THR URB WER Course Number* Section* Professor/Test Information Professor Name* Professor E-Mail Address* Professor Phone Please NoteBy checking this box, I confirm that I have discussed accommodations with the professor listed above. I confirm the professor has agreed to the date and time indicated below. I agree Test Date* Start Time Accommodations RequiredExtra TimeDragon Voice-to-TextWord ProcessorAlternate LocationScreen ReaderOther (Please specify)Reformatted Exam (Scanned or Recorded) If other, please specify Note to Professor (Optional) Please NoteBy checking this box, I confirm that I have met with and provided this professor with written notification of my eligibility for Support Services I agree Submit * Required