Proctor Request Form

This form is intended for use by web-based pharmacy students to request the use of a proctor for examinations that require the use of a proctor.  It is up to the instructor to identify the examinations requiring a proctor.

The following information must be provided as soon as possible, but at least two weeks prior to the scheduled date for the examination (if problems develop with the approval of a proctor by the faculty, a longer period of time is necessary..

Student Name:         Class Year:

Proposed Proctor Name:

Job Title:

Proctor mailing address:

Proctor Phone Number (including country code [if not US or Canada], area code and extension): 

Proctor Fax Number:

Proctor e-mail Address: 

An approved must fall into one of the following categories:

  1. An educator, counselor or administrator in a primary, secondary or collegiate educational system (students living in the vicinity of Creighton University should make arrangements in the School of Pharmacy and Health Professions to take exams on campus).

  2. A person authorized to administer tests working in a testing center in a community college, college, university, high school or military base.

  3. A county extension agent.

  4. An administrator of a hospital.

  5. A librarian or library testing center.

  6. A member of the clergy.

  7. Other individuals approved by the course instructor of record.

(*Note:  Proctor cannot be a relative, close personal friend, employee, employer, supervisor, subordinate or significant other of the student. The Instructor of Record, Pathway Director, and/or their designees must approve the proctor and may require a new proctor at any time and for any reason.)

Specify which of the above categories this person falls into, with explanation.

Which examinations will this proctor be used for (give course, description of exam and date/time examination to be given):

Proctor, please add one personal reference (Name, Phone number, Job Title, Relationship)

 

If the examination is computer based, has the equipment been tested to see if an exam may be taken from the proposed location:Yes  No

 

Revised 09/06/2007 01:11 PM