Distance Education Test Proctoring Form
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1Clemson University Student Disability Services
Test Proctoring Center Hours:
Test Proctoring Center
Fall/Spring:
Mon–Thurs: 8:00am-6:30pm
Class of `56 Academic Success Center Building
Fri: 8:00am-4:00pm
Suite 213
Summer:
Mon–Fri: 8:00am-4:30pm
836 McMillan Road, Clemson University
Clemson, SC 29634
Email:
clemsontpc@clemson.edu
Phone: 864-656-6848
TPC Fee
(TPC proctor completes/initial _______)
Fax: 864-656-6849
$20.00 CU-Affiliate
$40.00 Non-CU
Multiple exams @ $ _________ per exam
DISTANCE EDUCATION
TPC Fee Status
TEST PROCTORING FORM
Paid
Pay day of exam/attach receipt
SECTION I: Student Information (Student Completes)
Name: _________________________________________ Driver’s License/School ID: _________________
Phone #: _______________________________________ Email: __________________________________
College/Institution: _______________________________ Course Name #: _________________________
Instructor’s Name: _______________________________ Instructor’s Email: _________________________
Exam Date Requested: ___ ___/___ ___/___ ___
Exam Time Requested: ____________________
mm
dd
yy
I agree to comply with all Test Proctoring Center policies and procedures for exam proctoring. I understand that failure to do so may
result in losing the privilege of using the Test Proctoring Center. I understand that the exam will not be administered if my arrival time is
15 minutes after the instructor’s stated start time. I will be responsible for contacting my professor to reschedule the exam. I agree to
abide by Clemson University’s Academic Integrity Policy. I understand that violation of the Academic Integrity policy will be reported.
Signature: ____________________________________________
Date: _____________________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
SECTION 2: Exam Information Provided by Institution (TPC Staff Completes)
Total time allowed for exam: ____________
Deadline for taking exam: ________________
Approved materials/alternative formats/accommodations:
___ None
___ Formula/Tables
___ Scratch Paper
___ Calculator
___ Open Book
___ Open Notes
___ Computer (student’s or SDS Dept.) ___ Other _____________________________________________________
Special Instructions: _______________________________________________________________________
Exam Delivery Instructions (to be provided by Institution): __________________________________________
Exam Return Instructions (to be provided by Institution):
_________________________________________
Any violations of the Academic Integrity policy will be reported to the Institution.
Signature/Filled Out By: _______________________________________
Date: __________________
SDS Proctor: Please initial verifying the test proctor fee has been paid:
________
Time Started: ______________
Staff Initials: ________
Time Ended: ______________
Staff Initials: ________
Notes:
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