Proctor Verification Form

* All form fields are required  
Student Name
Student ID or Driver's License #
Photo Identification Type
Assessment Type Administered
Course Prefix
Course Number
Course Section
Course Title

Instructor
Instructor Email
Semester
Facility Name
Facility Phone Number

By checking the following boxes and submitting this form, I am confirming that:

I have supervised the student named above and testify that the student did not receive any assistance or use any materials unless specified in the written instructions from the course instructor.
I admitted the student to the examination after checking his/her picture identification. I collected all notes, worksheets, and other materials after administering the examination. I accept full responsibility for the security of this examination.

Proctor Name
Proctor Email
Proctor Initials