Faculty: Proctored Exam Request Form

Student Information

First Name:

Last Name:

Student ID:

Instructor Information

Instructor Full Name:

Instructor Email:

Instructor Phone:

Campus Mailstop:

Contact Information (if the person filling out the form is not the instructor)

Contact Full Name:

Contact Title:

Contact Email:

Contact Phone:

Classroom Test Information

Course Code (e.g. ACC 301):

Classroom Test Date:

Classroom Test Start Time:

Classroom Test End Time:

The class may have these aids for this exam:

  • Textbook
  • Reference books
  • Formula sheet
  • Calculator
  • Class notes
  • Computer
  • Internet access
  • Tape recorder
  • Dictionary
  • Other

Other classroom aid(s):

Proctor Test Information

Preferred Proctor Date:

Preferred Proctor Start Time:

Test will be sent to the office of Disability Suport Services via:

  • Inter-office mail to mailstop
  • Fax to 973-443-8932
  • Email to dshah@fdu.edu as email attachment
  • Dropped off by instructor or graduate assistant at the office of Disabillity Support Services

Upon completion, tests are to be:

  • Picked up by instructor or graduate assistant from the office of Disabillity Support Services
  • Sent via inter-office mail to mailstop indicated above
  • Delivered by student in sealed envelope
  • Other

Other return method:


Comments or questions:

  • I have read the Test Proctoring Policies and confirm that all information supplied in this form is correct and true to the best of my knowledge. I agree to the terms and conditions set forth by the office of Disability Support Services should corrections need to be made in this form. I understand that I will not hold the office of Disability Support Services or any of its officers accountable for any errors in the testing process due to mistakes and/or incorrect information supplied in this document.
Submit the Form


Policies and documentation

Please familiarize yourself with the information documented in the following document(s):

Extended time on test:

This accommodation constitutes “time and a half” based on standard exam time. Please take this duration of time into account when you specify start and end time for the proctored exam services.