Proctor Exam Request Form

Asterisk (*) indicates a response is required.

Phone: (563) 441-4088
Email: scctestcenter@eicc.edu
SCC-Belmont Testing Center Proctor Staff:
John Crownover

All fields are required.

Today's Date:

Friday, April 26, 2024 04:32

Student's Name:*

Student's Email:*

Student's Phone:
ex. 555-555-5555

Instructor's Name:*
TEAS if for TEAS

Course:*
If TEAS, put in Nursing, Radtech or Sonography

Test Name/Number:
i.e. "final exam, chapter 3", if TEAS enter which attempt, 1, 2, 3, 4 or 5

PLEASE NOTE:
All appointments must be confirmed with proctor.

It is the student's responsibility to make an appointment 72 hours in advance for all exams. Same day appointments can be made if time slots are available.
Appointments are 1 hour in length. If more time is needed, you must request it. The student will not automatically receive any extended time.
It is the student's responsibility to notify instructor; proctor information, day and time of the appointment.
You will receive a confirmation e-mail for your "Proctor Exam Day & Time" choice
Please contact the SCC-Belmont Testing Center Proctor Staff at scctestcenter@eicc.edu if you do not receive a confirmation e-mail. Students will not be allowed to test without a confirmed testing date and time email.

On the day of the test, the student must show a PHOTO ID to take the exam. If the student is more than 10 minutes late, he/she may reschedule for another day. The following items are NOT allowed in the testing area: books, book bags, cell phones, electronic devices, smart watches, purses, wallets, coats, and jackets. Please leave and lock all of these items in your car.

Monday	Tuesday	Wednesday	Thursday	Friday
8 - 9 a.m.	8 - 9 a.m.	8 - 9 a.m.	8 - 9 a.m.	8 - 9 a.m.
9:10 - 10:10 a.m.	9:10 - 10:10 a.m.	9:10 - 10:10 a.m.	9:10 - 10:10 a.m.	9:10 - 10:10 a.m.
10:20 - 11:20 a.m.	10:20 - 11:20 a.m.	10:20 - 11:20 a.m.	10:20 - 11:20 a.m.	10:20 - 11:20 a.m.
11:30 a.m. - 12:30 p.m.	11:30 a.m. - 12:30 p.m.	11:30 a.m. - 12:30 p.m.	11:30 a.m. - 12:30 p.m.	11:30 a.m. - 12:30 p.m.
1 - 2 p.m.	1 - 2 p.m.	1 - 2 p.m.	1 - 2 p.m.	1 - 2 p.m.
2 - 3 p.m.	2 - 3 p.m.	2 - 3 p.m.	2 - 3 p.m.	2 - 3 p.m.
3 - 4 p.m.	3 - 4 p.m.	3 - 4 p.m.	3 - 4 p.m.	3 - 4 p.m.
	4 - 5 p.m.	4 - 5 p.m.
	5 - 6 p.m.	5 - 6 p.m.
	6 - 7 p.m.	6 - 7 p.m.

Request Proctor Exam Day & Time

Time Allowed for Test*
How much time are you to be given to take the test

Testing Accommodations
If you have testing accommodations approved through disability resources, please ensure your instructor includes your accommodations when sending the test to the testing center.

Quiet Room Reservation

Check here if you have an approved testing accommodation through disability resources to take your test in the designated quiet room.

Read Aloud Software

Check here if you have an approved testing accommodation through disability resources to use read aloud software for your exam.

Read Aloud: Math Exams ONLY

Check here if you have an approved testing accommodation through disability resources to use a read aloud accommodation (for math exams specifically). An in-person reader will be assigned to read for you.

Scribe for Exam

Check here if you have an approved testing accommodation through disability resources to request a scribe for your exam. Note: request form must be submitted 72 hours in advance in order to coordinate scribe.

Please select the proctor exam day in the first box and your choices for an exam time will show in the next box. Then select the proctor exam time you want in the second box.

PLEASE NOTE: TEAS tests are only proctored at 8 a.m. Monday through Friday or 1 p.m., 2 p.m., 3 p.m. on Tuesdays and Wednesdays. TEAS proctoring is not available during mid-terms or final exams.

1st Choice		2nd Choice		3rd Choice
Exam Date:		Exam Date:		Exam Date:
Exam Day:	Exam Time:	Exam Day:	Exam Time:	Exam Day:	Exam Time:

I understand I need to notify my instructor about the day/time of my testing appointment once I receive confirmation of my approved time.

It is the policy of Eastern Iowa Community College District not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential family, parental or marital status, as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681-1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact EICC’s Equal Employment Opportunity Officer/Equity Coordinator, Eastern Iowa Community College District, 101 West Third Street, Davenport, Iowa 52801, 563-336-5222, equity@eicc.edu or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730- 1576, TDD (800) 877-8339 OCR.Chicago@ed.gov.