Exam Booking Form - Tenth Street

For students with academic accommodations.

*NOTE: Accessibility Services will Email the Instructor an Exam Request 3 days prior to exam date
Instructor Name
Instructor Email
Course Name
Course Number & Section
Student Name (List multiple names separated by a hard return.)
*NOTE: Instructors please fill in the information below.
Exam Type

Exam Type Quiz Test Midterm Final Exam Other
Exam Date for Class Exam Date for Class / MM / DD YYYY
Exam Start Time for Class Exam Start Time for Class : HH MM AM/PM
Exam Duration for Class

Exam Duration for Class 2 hours 3 hours Other
Exam Format

Exam Format Paper Exam Launchpad Moodle Exam Online Other
What is the passcode for the exam? Please note, this form is sent directly to accessibility services for security purposes.
Instructor Contact During Exam - How can the invigilator contact you, if the student has a question about the exam or if something goes wrong with the online exam? (Please include email and telephone)
Please indicate which apply to the exam and sign below:

Please indicate which apply to the exam and sign below: Open textbook Calculator allowed Computer required Compass Any form of notes allowed Formula or index card allowed Maps Ruler NONE Other
Instructor please indicate any other special instructions or requirements:
Instructor Signature (draw or write in box below)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.