The Office of Advising and Testing
DISABILITY SERVICES TESTING
ACCOMMODATIONS FORM 

This form must accompany ALL tests to be given in the
Special Populations Testing Area (City Park Campus, Building 2, Room 302)

Student’s Name   	Student ID Number     
Instructor’s Name 				Instructor’s Building #/Room#        	
Instructor’s Phone					Course Prefix/Section Number  
AIDS ALLOWED: No aids will be permitted unless specifically authorized.
 Calculator			  Dictionary   	 Scantron 882E/ES(green,1-100,A-E)

 Notes                                                	 Translation Device/Book   	 Scantron 2052 (blue, 1-100, 1-5)

 Note card   3”X 5”   4”X 6”    	  Blue Book   Scantron F-165(red, 1-100, A-E)
                         5”X 7”                  	
 NCS ScanForm 19641		            	 Other 

 Textbook     	 Scantron 881E/ES (green, 1-50, A-E)

PLEASE FILL OUT YOUR SPECIAL INSTRUCTIONS FOR THIS PARTICULAR STUDENT:

Finish by this date/time:

Method of Exam Delivery: 	 E-mailed to the City Park Testing Center at cityparktesting@dcc.edu
 Hand-delivered to Testing Center (Bldg. 2 Room 302) by Instructor

	
Method of Exam Return:   	 Instructor will pick up exam from Bldg. #2 Room # 302	
				 Testing Center will return test to __________________.

Instructor’s Signature	       		Today’s Date 
										Form 1468/002 (01/15)