Sample Instructor Agreement Form

Student:_______________________  Instructor: _______________________
Class (Title/Number): ______________________________________________ 
Quarter/Semester (check one):   __Fall   __Winter   __Spring   __SSI   __SSII

We have discussed and agree upon the following accommodation arrangements:

Exam 1:  Start time ____  End Time____   Location ________________
         Exam Assistant?   Yes/No   (Name) ________________________ 
         Proctor assigned? Yes/No   (Name) ________________________

Exam 2:  Start time ____  End Time____   Location ________________
         Exam Assistant?   Yes/No   (Name) ________________________ 
         Proctor assigned? Yes/No   (Name) ________________________

Exam 3:  Start time ____  End Time____   Location ________________
         Exam Assistant?   Yes/No   (Name) ________________________ 
         Proctor assigned? Yes/No   (Name) ________________________

Other accommodation arrangements:

 

 

 

 


Date:  ____________

Student Name:____________________________ Signature: _________________________
                                   (Printed or Typed)

Instructor Name:___________________________ Signature: _________________________
                                   (Printed or Typed)