CCCPA Acknowledgement Proctor Guide

Acknowledgement

The Proctor Guide contains instructions for exam administration. It is extremely important that all proctors follow the same procedures. You should become familiar with the instructions presented in the guide before administering the exam. In following these procedures, you will assure the validity of the exam results and greatly reduce the likelihood of confusion or error before, during, and after the exam.

When you have finished reading this guide, are familiar with the instructions provided and have completed the conflict of interest part of the form, please acknowledge by signing below.

Indicate the relationship between the proctor and the examinee(s) in the space provided (i.e. employer, supervisor, supervising pathologist, co-worker, no direct relationship etc…)

1. Contact Information *This question is required.

First Name

Last Name

Title

Institution

City

Province

Email Address

2. Conflict of interest *This question is required.Select one choice below and provide further information if there is a potential, perceived or real conflict of interest.

3. Describe the circumstances that may be considered a conflict of interest:
*This question is required.

3. Examinee Names

Space Cell	First Name	Last Name	Email
Examinee 1	Examinee 1: First Name	Examinee 1: Last Name	Examinee 1: Email
Examinee 2	Examinee 2: First Name	Examinee 2: Last Name	Examinee 2: Email
Examinee 3	Examinee 3: First Name	Examinee 3: Last Name	Examinee 3: Email
Examinee 4	Examinee 4: First Name	Examinee 4: Last Name	Examinee 4: Email
Examinee 5	Examinee 5: First Name	Examinee 5: Last Name	Examinee 5: Email
Examinee 6	Examinee 6: First Name	Examinee 6: Last Name	Examinee 6: Email

4. Proposed exam writing location.

5. Proposed dates.

1
2
3

6. I have read the Proctor Guide, I understand my role and responsibilities as a proctor, I have included my relationship with the examinee and any conflicts of interest and agree to abide by the guidelines provided. *This question is required.I understand I must be present and remain in the exam room for the entire duration of administering the exam.

Clear

Signature of