DSS Exam Accommodations Request Form

Student Information

Student's name:

Student's email address:

Course Information:

     Course Name: I.e., Principles of Human Behavior

     Course Number: I.e., PSY 100

    Section #:

     What time does the course meet?  

     What days does the course meet?

Exam Information

     Date of test:

    Is a different date or time requested? Please indicate:      

    Accommodations needed (Please indicate what you need to take this exam.)     

Instructor Information

     Instructor's name:

     Instructor's email address:

Comments: Enter additional comments if needed.