250 Bedford Park Blvd. West L e h m a n C o l l e g e Shuster Hall, Room 238 Bronx, NY 10468-1589 The City University of New York Phone: (718) 960-8441 Fax: (718) 960-7489 Student Disability Services - Testing Accommodation Form SECTION 1: TO BE COMPLETED BY THE STUDENT Student’s Name: ____________________________ Phone Number: _________________________ Course: ___________________________________ Professor: _______________________________ Date of exam: _____________________________ Class time of exam: ___________ Classroom: ___________ It is the student’s responsibility to submit this form to the Office of Student Disability Services at least one week (7 days) prior to the exam in order to guarantee accommodations and available space. This is an official request to take the above stated exam with accommodations under Section 504 of the Rehabilitation Act of 1973 and the American with Disabilities Act of 1990. With this request, I agree to follow the procedures as per arrangements with the Office of Student Disability Services. ____________________________________________________ ___________________________ Signature of Student Date SECTION 2: TO BE COMPLETED BY INSTRUCTOR I agree to have the Office of Student Disability Services coordinate exam accommodations for the student in accordance with the date/time listed below. Date of Exam: ___________________________ Time of Exam: __________________ Actual amount of time that class receives for exam: Hours: ____________ Minutes: __________ Special Instructions: (open book, notes, calculator, etc.) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ If exam conflicts with the student’s schedule, please indicate an alternative date and time _______________________ Please confirm how the Office of Student Disability Services (SDS) will obtain exam: ____ Exam will be e-mailed to merrill.parra@lehman.cuny.edu and a copy sent to disability.services@lehman.cuny.edu ____ Exam will be faxed to (718) 960-7489 ____ Exam will be dropped off at Shuster Hall, Room 238 ____Exam will be left with department secretary for pick up by SDS staff. The completed exam will be returned to your department unless otherwise indicated? ______________________________ _____________________________________________________________________________________________ _________________________________________ Please provide scantron sheets or blue books if required. After signing this form, please return to the student who will drop it off at Shuster Hall 238. Thank you. Signature of Professor: ________________________________ Phone: ____________________ E-mail: _____________________________________________ Date: ______________________ White & Pink copy returned by student to Shuster Hall Rm. 238. Yellow copy for faculty.