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ONLINE STUDENTS--DISTANCE LEARNING TESTING

Remote Test Site & Proctor Approval Form

This form is to be completed ONLY by students outside of the Jacksonville, FL (First Coast) area.

Remote Site Approval: Location must be a college, university or military Educational Services Office.
No other locations will be approved.

Remote Proctor Approval: Must be an employee affiliated with the schoolÕs assessment/testing office or program and authorized to administer exams on behalf of the appropriate institution. 

Military Test Proctors: Must be appointed or assigned to the Educational Services Office
Fees: Student is responsible for any fees charged by the remote test site.

   
STUDENTS MUST NOT SCHEDULE ANY EXAMS TO BE ADMININSTERED AT A REMOTE SITE UNTIL THIS FORM HAS BEEN APPROVED BY FCCJ.

STUDENT INFORMATION – DATE ____________________

StudentÕs Name: _____________________________________________________         StudentÕs SSN:  ___ ___ ___ - ___ ___ - ___ ___ ___

                                          Last                             First                               middle initial

Daytime Telephone Number:  (______) __________________________________         Email Address: _______________________________

Course/class information that requires remote test site proctor:        TERM: ______________________________________________________

Course Name: __________________________    Reference Number:  ___ ___ ___ ___ ___ ___      Instructor: ___________________________

Course Name: __________________________    Reference Number:  ___ ___ ___ ___ ___ ___      Instructor: ___________________________

Course Name: __________________________    Reference Number:  ___ ___ ___ ___ ___ ___      Instructor: ___________________________


REMOTE TEST SITE INFORMATION

Remote Test Site: _________________________________________   ProctorÕs Name: _____________________________________________

                                                      College, university or ESO

Mailing Address: __________________________________________   ProctorÕs Title:    _____________________________________________

Mailing Address: __________________________________________   ProctorÕs Email:  _____________________________________________

________________________________________________________ Assessment Center Phone Number:         (______) ____________________

City                              State                   Zip Code                                           

School Web Page Address: __________________________________ Assessment Center FAX Number:          (______) _____________________

I hereby certify that I will administer exams under conditions required and requested by Florida Community College at Jacksonville.

_________________________________________________                                    _________________________________________________ 
ProctorÕs Printed Name                                                                                                   ProctorÕs Signature

PLEASE EMAIL OUR OFFICE TO NOTIFY US WHEN THIS FORM HAS BEEN SENT TO US.

THIS FORM WILL NOT BE ACCEPTED WITHOUT PROCTORÕS PRINTED NAME AND PROCTORÕS SIGNATURE.

 SEND COMPLETED FORM TO:

OPEN CAMPUS DISTANCE LEARNING OFFICE
FLORIDA COMMUNITY COLLEGE AT JACKSONVILLE
601 WEST STATE STREET, Rm. 107
JACKSONVILLE, FL 32202
TELEPHONE: 904.632.3118
FAX:  904.632.5098
EMAIL: assessme@fccj.edu

FCCJ DLO SERVICES STAFF ONLY:

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Verified StudentÕs Registration

  

Verified Testing Site

  

Verified ProctorÕs Name

  

Updated Data Base   –   Student, Proctor & Site

  

Updated Billing Log

  

Date Verified & Updated:                          /               /2007

Date Exam Sent:                                     /                /2007   

Staff Initials: