Accommodated Testing Request

Bethel University — Disability Services

This form is to be completed by a Professor on behalf of a student needing disability-related testing accommodations. Please fill out the form as completely as possible.

Note: all items marked with * are required.

Student's Name:*	Student's ID:*	Today's Date:*
Course Number/Section*	Date of Test/Exam
Professor name*	Professor phone	Professor email

Preferred Date/Time for Testing
I give permission for this test to be administered at an alternate time if the student’s class schedule or room availability precludes the test being administered at the preferred time.
Yes  No
Additional Comments
Test will be delivered to Disability Services Office 24 hours in advance of scheduled testing session. (please check one) Professor/designee delivers test to Disability Services Office  Professor faxes test to Disability Services Office (651-638-6351)  Professor e-mails test to Disability Services Office
Testing accommodation(s) requested for the student: (please check all that apply) 1.5 Extended Time  2.0 Extended Time  Separate testing room  Calculator Allowed  Computer Needed  Enlarged Text  Other
If selected Other, please specify
Please list any special testing instructions such as permission to use notes, books, or other materials.
Test/exam will be returned to professor: (please check one) Professor (or designee) picks up test/exam from the Disability Services Office (CC427)  Disability Services Office returns test/exam to professor in sealed confidential envelope via campus mail to professors PO Box
Upon receipt of this form Disability Services will contact the student to confirm testing arrangements. Questions? Call Deb Cupryna 651-638-6833 or email disability-services@bethel.edu.