Distance Learning Facilitator's Form

If you will be taking your course totally "at a distance", that is without ever coming to campus, you must complete this form and forward it to your instructor for approval before the beginning of the class. Be sure to complete all sections and attach the appropriate identification.  Fax it to your math instructor at 207-741-5531.  Alternately, you may mail it to your instructor's attention at Southern Maine Community College, 2 Fort Road, South Portland, Maine 04106.

Remember, facilitators must be education officials at a university, community college or public school site, other governmental or community officials or, if such persons are unavailable, other people approved in advance by the instructor. Relatives cannot be facilitators.

Please Print Clearly
Course Information
Course # and Title
Term (ex: Summer 2008)
Student Information
Student's Name
SS#
Facilitator's Information
Name/Title
Affiliation
Street Address
City, State, Zip
Email
Phone/Fax

Facilitator's Contract

Thank you for agreeing to facilitate testing for this student. You will receive tests by email in the form of an Adobe Acrobat .PDF file, by fax or in the US mail which ever is most convenient and secure for your situation.  You may return the completed exams by fax to (207) 741-5531 or by US mail.  The student is responsible for supplying postage and envelopes to you if you mail exams.

Please be sure to:
    -Complete the Facilitator's Information above.
    -Attach your business card or a photocopy of some form of identification.
    -Read and sign the statement of responsibility below.

Statement of Duties and Responsibilities:  I will keep all test materials in a secure location when not in use. I will not make duplicate copies of tests without permission of the instructor. I will not give the student access to the test before it is administered. I will check identification to be certain the correct person is taking these tests. I will return completed test materials as soon as possible. I will return or destroy all unused test materials.

I have read the description of my duties as facilitator. I understand that I am responsible for preserving the integrity of the test materials for this course and the testing process for the above named student.

Signed: Dated: