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Exam Proctoring Request Form (DSS)

The Pathways to Academic Success Program (DSS) conducts Exam Proctoring for HNU students registered with the program.

Exams are proctored by a Proctoring Coordinator. Please note that the staff member does not remain in the testing room with the student while the student is taking the test. We do, however, require that the student leave all belongs — except a pen/pencil (and any other materials specified by the instructor) — with the staff member. We provide monitoring of the testing room.

The Exam Proctoring Form must be submitted at least 48 business hours prior to the desired test date. All late or incomplete requests will not be accepted and the exam will not be administered.

Please Note: It is standard practice for the exam to be proctored at the same time that the rest of the class is completing the exam. Exceptions may be made if the extended time will create a conflict with another class.

If the class is offered outside of normal business hours (i.e. evenings or weekends) it is the instructors responsibility to determine, an alternate time for the test to be proctored before submitting an Exam Proctoring Request Form.

Fields marked with an asterisk (*) are required.

Instructor Information

Instructor Name*
Contact Phone Number* (xxx-xxx-xxxx)

Student Information

Student Name*

Course Title

Course Title*

Exam Information

Exam Date (mm/dd/yyyy)*

Exam Time Ex. 9:00am*

Materials Allowed
Other Materials
Exam Type
In what format will the test be provided?
Paper (Instructor will drop off exam at Brennan 81)
Email (Instructor will send exam to examproctor@hnu.edu)
Method of Return: (Select one)
Instructor will pick up exam from Brennan 81 during business hours.
Proctoring Coordinator will scan and email exam within 1 business day. A hard copy of the exam will be mailed to Instructor via campus mail

According to the Disability Support Services (DSS) Accommodations Letter provided to the Instructor, the Student should receive the following accommodations:

Extended Time
Low Distraction
Use of a Laptop
Modified Test Format
For questions or assistance regarding any of the above, please contact the Coordinator of Disability Support Services at dss@hnu.edu

Please use this space for any additional comments or directions: