TEST ACCOMMODATIONS REQUEST FORM
COUNSELING CENTER
700 UNIVERSITY AVENUE
MONROE, LA 71209-1135
Office: (318) 342-5220 Fax: (318) 342-5228

This form is NOT a certification of disability.
Please complete the appropriate section of this form. Thank you.

I. Student
Name: ___________________________________ Date:___________________
Date of Birth: _______________________Telephone No.:__________________
Email Address: ____________________________________________________

II. Faculty
Name: ____________________________________ Dept. __________________
Department Location: ______________________Telephone No.:_____________
Email Address: _____________________________________________________
Approved Test Date and Time: ________________________________________
Approved Test Aids (i.e., calculator, text, class notes) ____________________
If calculator approved, specify what type: ______________________________
Indicate (X) the amount of time allowed for students taking test in the classroom:
50 Minutes ( ) 75 minutes ( ) 150 minutes ( ) Other (_________minutes)
Method of test delivery:
fax - ext. 5228 ( ) personal delivery ( ) pick-up ( ) email ( )
Faculty Comments: _______________________________________________________________
_______________________________________________________________

III. Counseling Center
Test Arrival Date: ____________Test Received By: ____________________
Counseling Center Comments: _______________________________________________________________

IV. Test Return Confirmation
The signatures below confirm that the attached test has been returned to the faculty or department from which it originated.
Date: _____________________ Received by: ____________________________
Delivered by: ___________________

Academic dishonesty, attempted or accomplished, in any form is unacceptable at the University of Louisiana at Monroe. If clear physical evidence indicative of academic dishonesty is obtained by Counseling Center staff during the testing process, the staff member will have the authority to immediately confiscate the test as well as the item the student is using to cheat. The incident shall be reported to the instructor for further investigation. If the student is found guilty of academic misconduct (cheating), the instructor will report the incident in writing to the department head and/or associate dean (or other appropriate administrator), who will report the incident in writing to the Office of Judicial Affairs in order for an appropriate censure to be determined.