Instructor Acknowledgement of Accommodated Testing

Student's Full Name*

Student's Email Address*

Please use the student's CFCC email address ending in mail.cfcc.edu

Student's ID Number

Student's phone number

Course*

Instructor's Name*

Instructor's Email Address*

Please use the Instructor's CFCC email address.

Instructor's Cell Phone Number*

This number will not be shared with the student. This number will only be used if the Student Accessibility Services Office has a test-related question before or during the test.

Campus Location*

Wilmington Campus - Union Station 218
North Campus - NA 106B
Burgaw Campus - SAS staff will contact with room number.
Surf City - SAS staff will contact with room number.

Requested Test Date*

Requested Testing Time*

:

Do you agree with this date and time?*

Yes
No

Enter alternate date and time.

Student has requested additional testing accommodations (e.g. read aloud, enlarged copy, etc.):

Yes
No

Student requested accommodations:

How much time are students without accommodations given to take the exam?*

The student may use the following materials during testing.*

Please add any passwords or other information you do not wish the student to see before the test.

Information in this section will not be shared with the student.

Test Format

Paper/pencil
Computer

This test must be completed by

Please specify a time.

How will the test be provided to Accessibility Services?

Instructor will bring hard copy to SAS office (U-218)
Attached to this form (SAS will print)

Attach Test Document (PDF or Word Document)*

Drop files here or

Accepted file types: pdf, doc, docx, xls, Max. file size: 64 MB.

How will the test be returned to you?*

Left at Accessibility Services to be picked up by instructor
Delivered by student
Scanned and emailed by SAS to instructor’s email address

Enter office/classroom location.

Additional Instructions for the Students (Optional)

NOTE: Students also receive these instructions via email.

Instructor Acknowledgement of Accommodated Testing

Quick Information

Hours

Location

(910) 362-7000

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