Nursing Test Request Form

This form must be completed and returned by student at least 72 hours (3 business days) prior to the test date.

To be filled out by the student:

Please provide the following information

Student name: *

Student phone: *

Student email: *

Semester Lead Instructor name: *

Semester Lead Instructor email: *

Course title: *Example: Nurs 1010

Campus:

Knight Campus (Warwick)

Flanagan Campus (Lincoln)

Liston Campus (Providence)

Newport Campus

Please provide information about when the test is being given to the rest of the class.

Class exam date: *

Class start time: *

Class end time: *

DSS exam date: *

DSS start time: *

If scheduling date and start time are different than class time, state when and why:

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