PROCTOR REQUEST FORM
NOTE: Please complete a separate form for each course. Proctor and student must follow guidelines for test proctoring
as outlined and complete the attached “proctor agreement and appointment confirmation form.”
Current Savannah State University (SSU) students who do not reside within the Savannah area and are enrolled in an
online course and require a test proctor may utilize this form. Please allow up to 5 business days for proctor request
approval. All proctor request forms must be completed no later than the 2nd week of classes or as stated in the course
syllabus. Forms submitted after the deadline will not be accepted. No exceptions. See your instructor’s syllabus for
more information. If you have questions or need to check on the status of a request, call 912.XXX-XXXX or email
[email protected].
PROCTOR REQUIREMENTS/RESPONSIBILITIES
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Must be a staff member at a college test center, professional full-time librarian, or advisor of military program.
Must have a valid email address associated with the college/university, library or military.
Cannot be a family member, employer, or someone with whom you work.
Military students may use an education or test control officer associated with the military.
Students with a disability or require special accommodations must contact the Office of Disability Services at
912.358.3115 for suggestions in identifying an appropriate proctor and/or to provide supporting documents for
such accommodations.
Must be able to administer tests online, using a computer with reliable access to the internet.
Must be verified by SSU as a qualified proctor (including employment and work title) prior to testing.
STUDENT REQUIREMENTS/RESPONSIBILITIES
Students are responsible for securing a proctor and paying any applicable fees charged by the proctor. SSU reserves the
right to reject requests or proctors for any reason. Students will receive communication if a request has been denied.
For all approved requests, exam materials will be emailed and/or mailed to the approved proctor.
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Students must present valid photo identification (a current driver’s license, SSU ID, or passport).
Students are required to provide the course number, instructor’s name and test information.
Students must refrain from the following:
o Any form of academic dishonesty to include but, not limited to
 Cheating on test by giving, receiving, and/or soliciting assistance of any kind.
 Using unauthorized test aids such as electronic, photographic and listening devices, cellular
phones, papers, pamphlets, papers or notes of any kind, and any other noted prohibited items,
unless otherwise stated in writing by the instructor.
 Plagiarism (talking to and using the ideas or writings of another as one’s own).
Violations of these offenses could result in disciplinary action as outlined in the SSU Student Handbook.
Once your proctor form has been received and approved, you will receive a confirmation through your SSU student
email address. If you have not received a confirmation within five (5) business days of submitting your proctor form,
please check to make sure we received it.
Proctor Agreement and Appointment Confirmation Form
Semester ______________________
Deadline ______________________
Savannah State University – OFFSITE TESTING
Forms submitted after the deadline will not be processed. No exceptions!
Section I – Student Information (To be completed by the student)
Student’s Name
(Last, First, MI)
Student ID Number (ex. 915XXXXXX)
_________________________________________________________________________________________________________________________
Telephone Number
SSU Email (no personal email addresses)
Test Type (Select one): ____ Midterm
____ Final
Please include course information below—you may list up to three (3) online courses on one form.
1)
Course Number – Section
Instructor
Course Number – Section
Instructor
Course Number – Section
Instructor
2)
3)
Please select the item below, if needed:
____ I am approved for and request special accommodations for testing (Counseling and Disabilities Services must forward confirmation of services
needed to test proctor prior to test appointment confirmation). Check all that apply below.
___ extended time
Specify:_____ time / half
___ low-distraction room
___ reader
_____double-time ____ Other (Explain): __________________________________________
_____ alternate form of test (ex. Braille)
Section II – Proctor Information (To be completed by the Proctor)
__________________________________________________________________________________________________
Proctor’s Name
Institution Name
__________________________________________________________________________________________________
Proctor’s Email Address
Proctor’s Phone #/Fax
__________________________________________________________________________________________________
Proctor’s Mailing Address
__________________________________________________________________________________________________
I am employed as a (Select one):
___ College Testing Staff
___ Full-time Librarian (Local Public Library) ___ Program Advisor of Military Program
Section III – Appointment Confirmation (This form is not considered complete until a confirmation of appointment has
been established and signed by the proctor.)
MIDTERM EXAM DEADLINE
(TEST MUST BE COMPLETED BY DATE BELOW)
FINAL EXAM DEADLINE
(TEST MUST BE COMPLETED BY DATE BELOW)
DATE RANGE: From xx/xx/2014 -- xx/xx/2014
DATE RANGE: From xx/xx/2014 -- xx/xx/2014
DATE/TIME________________ COURSE_________________
DATE/TIME________________ COURSE_________________
DATE/TIME________________ COURSE_________________
DATE/TIME________________ COURSE_________________
DATE/TIME________________ COURSE_________________
DATE/TIME________________ COURSE_________________
SECTION IV – Proctor Approval & Agreement (To be completed by the Proctor)
We will confirm your position as stated above. Once you have been approved as the student’s proctor, we will forward
the test(s) to you.
EXAM PROCTORING: Exams must be administered and supervised by you in your place of business. Please note: we
must send all exams and/or information to your business email address. Exams cannot be sent to a private email
address or administered in a private residence. Exam materials will be emailed to the proctor’s email address as list
above in approximately three (3) business days prior to the listed examination date/or appointment date.
I have read the information and proctor responsibilities for administering test(s) to the student listed above. I further
confirm that I am not related to the student named above and will confirm the identity of the student prior to the start
of the test. I agree to administer the test(s) as instructed to the above student and I will not leave him/her unsupervised
during the test administration. I agree to return all test(s) and related materials as instructed.
PROCTOR SIGNATURE __________________________________________________________DATE _________________
This form must be submitted by the proctor and NOT the student. PLEASE SUBMIT THIS COMPLETED FORM TO:
Savannah State University – XXXXX Office at [email protected] or fax 912.358.XXXX .
02/24/14