Office of Disability and Diversity Services

Pat Lakey

8350 North Tamiami Trail

SMC-C107

Sarasota, Florida 34243-2025

(941) 359-4714

(941) 359-4701 (FAX)

(941) 359-4666 (TTY)

EXAM REQUEST FORM

STUDENTS WITH DISABILITIES SERVICES
 

Student Name:

Course Name and Number:

INSTRUCTOR

Complete entire form. Print and ATTACH TO THE EXAM
and SEND this form AND exam to Pat Lakey. OR print and Fax form to Pat Lakey (941.359.4701)

Class Exam Date (mm/dd/yy): Class Exam Time: Select 7:00 A.M. 7:30 A.M. 8:00 A.M. 8:30 A.M. 9:00 A.M. 9:30 A.M. 10:00 A.M. 10:30 A.M. 11:00 A.M. 11:30 A.M. 12:00 P.M. 12:30 P.M. 1:00 P.M. 1:30 P.M. 2:00 P.M. 2:30 P.M. 3:00 P.M. 3:30 P.M. 4:00 P.M. 4:30 P.M. 5;00 P.M. 5:30 P.M. 6:00 P.M. 6:30 P.M.

Amount of time CLASS is allotted for exam: 0 1 2 3 4 5 Hours 0 15 30 45 Minutes

Instructor authorizes the CLASS to use the following: (Select all that apply)
Scrap paper  Notes   Textbook(s)   Formulas   Charts
Tables    Calculator   Computer
Other:

Scheduling Instructions: (Check one)

Student may schedule exam for another date. SELECT YES NO
Exam must be completed by date (mm/dd/yy):
 

Instructor requires answers on scantron sheet. SELECT YES NO

COMPLETED EXAM RETURN PROCESS

  SELECT Hold, for pick up at SDS office (Sarasota-Manatee Campus, C107) Campus Mail FAX Snail Mail to Home Address

If selected above, indicate FAX number:

If selected above, indicate mailing address (other than Campus Mail)

Instructor Name: Date:

Instructor’s Signature: