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Request to Proctor

In compliance with the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, and Prevailing University Policy, Adelphi University makes academic accommodations for students with disabilities; the Student Access Office (SAO) coordinates these accommodations. Accommodations for disabilities are determined by SAO on an individual basis, according to documented need and verified by a formal Accommodations Approval Letter.

*First Name:

*Last Name:

*Instructor's Name:

*Course Title:

*Date of Exam:

*Exam Time:

*What type of Exam?

*Is this exam being given:

In-Person

Online

*Please check all that are needed:

Screen Reader for Exams

Accessible Desk

Scribe

Computer for Essay

Enlarged Print

Distraction-reduced environment

Extended time

Other

*Where is the exam taking place?

Garden City Campus

The Hauppauge Education and Conference Center

Manhattan Center

Hudson Valley Center

It is the student's responsibility to submit a completed Request to Proctor form one week prior to the scheduled examination date.

*I will not receive nor give information regarding the contents of the exam:

I Agree

*Cell Phone Number:

{xxx-xxx-xxxx}

*Email Address:

*Retype Email Address:

(For Student Access Office Use) Academic Department Signature

(For Student Access Office Use) Date and Time signed