Signed Protocol_________ Entered by __________ Date _______

Margaret A. Staton

Office of Disability Services

www.gsu.edu/disability

· Georgia State University · MSC 3BO245 · University Plaza, Unit 3 · Atlanta · GA · 30303

· Phone: (404) 463-9044 · Fax: (404) 463-9049 · Email: DISMAIL@langate.gsu.edu

In Person: New Student Center, Suite 230

Fall and Spring Hours: Monday-Thursday, 8:00am-8:00pm · Friday, 8:00am-6:00pm

Call us for summer hours.

¨¨ Request for Individualized Testing Accommodations ¨¨

R.I.T.A.

Student Information: Fill in all the blanks. Incomplete forms cannot be accepted.

Name_____________________________________________________________________________________

SSN #________________________________________________

On these exams, are you approved to use: ___test on disk ___ test on tape

____enlarged text ___special assistance ___adaptive technology? (Specify assistance/tech needs)

______________________________________________________________

Do you need a room with specific technology? No___ Yes ___ Room #______

Semester/Year________________________________________

Course # & Dept.______________________________________

Day(s) Class meets________________ Start Time______________ End Time_________

Classroom Location: Bldg___________________________ Room #________________

Instructor's Name__________________________________Phone #_________________

Instructor's Office Location: Bldg_____________________ Room #_____________

I understand that any changes in exam dates, times, or conditions for testing must be given to

ODS by the instructor. My signature indicates I am responsible for knowing the exam schedule on this form,

and I am responsible for knowledge of any changes to this testing schedule.

Student's signature: ___________________________________________________________

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R.I.T.A.

INSTRUCTOR INFORMATION

Student will take exams at Disability Services as I have indicated below:

Date exam is to be Start Time Start any Length of exam

Taken at ODS at ODS time that day? in class? (hours/minutes)

1. ___________________ ___________________ Y N ____________________________

2. ___________________ ___________________ Y N ____________________________

3. ___________________ ___________________ Y N ____________________________

4. ___________________ ___________________ Y N ____________________________

5. ___________________ ___________________ Y N ____________________________

6. ___________________ ___________________ Y N ____________________________

Open Book? Yes No Scrap Paper? Yes No Open Notes? Yes No

Dictionary? Yes No OTHER: __________________________________________________

Calculator? Yes No SPECIFIC TYPE OF CALCULATOR? _______________________

Unproctored breaks? Yes No conditions for breaks: __________________________

Is test administered to the class on computers? Yes No

Ø I will e-mail the exam to DISMAIL@langate.gsu.edu Yes No Note: E-mailed exams received

after 4:00 p.m. cannot be made available to students until the following business day.

Ø I will fax the exam. Yes No 404-463-9049

Ø I will deliver the exam. Yes No (Campus mail not recommended)

Ø Disability Services will pick up the exam between 1:30 – 3:30 PM. Yes No

Picking up the exam from the classroom may result in a violation of privacy for the student.

ODS can only pick up or deliver exams between 1:30 and 3:30 PM. If ODS does not receive an exam in

time to administer it according to this exam schedule, please contact ODS with information for rescheduling the exam.

Pick up from Building _______________ Room # _______ Day of Exam Day before Exam (circle one)

Return the completed exam to the following location:

I will retrieve the Exam

Building _______________ Room# ____________ Yes No

Instructor's Signature ___________________________________________________________________

I understand this form is null and void unless accompanied by a student accommodation form

that specifies accommodations for tests/exams.

E-mail Address_______________________________________________________________________

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