DRD Pilot Testing Parameter Form-Math Department

DRD Pilot Testing Parameter Form- Math Department

Santa Rosa Campus- Jeff Kunde Hall, Room 204

Appointment Only Testing

Student's Name(s)

Instructor's Name*

First Name

Last Name

Instructor's Email*

Course*

Exam Date*

Additional dates (must have the same testing parameters)

Start Time

Instructor Selected Time

Length of exam WITHOUT extra time

ACCOMMODATIONS AUTHORIZED FOR THIS EXAM:

Extended Time Assistive Technology (Read & Write Gold, Dragon, etc.) Other

Extra Time

1.5x 2x

Type of Assistive Technology (Read & Write Gold, Dragon, etc.

Other:

Please check all that apply

Calculator Allowed Computer Required Open book Notes Allowed Other (Scantron, Blue/Green Book, etc.)

Calculator Allowed

Basic Scientific Graphing

Open Book: Text:

Notes Allowed:

Other (Scantron, Blue/Green Book, etc.):

Additional Instructions

UPLOAD EXAM HERE

No File Chosen

File uploads may not work on some mobile devices.

If no exam is uploaded, please mark the box for how you plan to submit the exam.

Delivering a hard copy of the exam to Kunde 204 BEFORE the start of the exam. Emailing the exam to aorourkesargent@santarosa.edu BEFORE the start of the exam. Sending the student with the exam in a sealed envelope at the time of the exam.

How will the exam be returned?

Instructor will pick up from proctor in Kunde 204 Mon-Thurs 5pm-9pm Exam delivered to Instructor's MAILBOX in Kunde Hall. Student Self-Deliver to Instructor (in a sealed envelope).

Instructor Signature*

[clear]

Use your mouse or finger to draw your signature above

Instructor Phone Number

DRD OFFICE USE ONLY:

Start-Time:___________ Max-Time:__________Time-Completed:___________ Proctor:__________________________

Delivered-By:________________ Pick-Up-Signature:______________________________