Quinsigamond Community College
Disability Services, Ext. 4471
Exam Checklist

Please fill out the following form completing all 'required' fields and providing as much additional information as possible.  When complete, click the Submit Form button located at the bottom of the page.   Please note:  Testing begins at 8:00 am and will have to be completed by 6:00 pm Monday-Thursday and 5:00 pm on Fridays.
 

Today's Date:  2/12/2012
Student's Name:  (required)
Course Number:  (required)

Instructor: (required)
Phone & Extension:  (required)
Email:  @qcc.mass.edu (required)

  I:  General Instructions:
 

Location:  All exams need to be taken on the campus where the class is held. (required)
Worcester Campus
Southbridge Campus

Exam Date: (required)
Class Start Time: (required)
 

Time Allowed In Class For Exam:  (required)
.5 hours       1 hour       1.5 hours       2 hours
Time Allowed Other:


II: When Must the Student Take the Exam: (check one) (required)

Same as regular class time. Allowed to start earlier.
Close to regular class time. Other arrangements.

III. *Specific Instructions:  (check all that apply)

Do not write on exam.

Graphing calculator allowed.

Notes allowed.

Scientific calculator allowed.

3"x5" note card allowed.

Regular calculator allowed.

Open book.

Dictionary allowed.

Scrap paper allowed.

Computer allowed.

Show all work.

Return all work.

Enter additional instructions:

IV. Method for Delivery of Exam to Disability Services, Room 246A:  (check one) (required)

Instructor attached exam (Word or other Electronic document) to this form
To attach exam(s) to this form, select the exam (using the "Browse" button).  Click "Open" after selecting the document.  Next, click the "Attach Document" button.  The exam will be listed as attached and will be submitted along with the form, as it is submitted.  You can attach other documentation as needed, one file at a time.

Instructor will e-mail the exam separately to:  disabilityservices@qcc.mass.edu

Instructor delivers exam

Student will bring exam in a sealed envelope
Online Exam:  password (if needed): 


  V.  Method for Returning Exam to Instructor:  (check one)

Instructor picks up the exam from Disability Services, Room 246A.

Student will return the exam to the instructor in a sealed envelope.


Thank you for completing this online form!

Disability Services office use only

* “Specific Instructions” read to student by Disability Services staff:

     _________________________________________                     _______________________
                          Student’s Signature                                                                              Date