Text for RITA Form

The scanned version of the sample RITA form contains the following text.

Request for Individualized Testing Accommodations (RITA)

Please print, press firmly, use ballpoint pen.

Course Information

Section 1: To be filled out by student

• Name
• Phone number
• Course name
• Number
• Department phone
• Instructor's name
• Office phone

Section 2: To be filled out by the instructor

The student has presented me with a CSD Student Accommodations Form. I agree to the testing accommodations specified. Exams are to be administered by CSD on the following dates and start-times. Note: If start-times are negotiable (within CSD hours of operation) place an (N) in the space designated for time.

1. Date/time
2. Date/time
3. Date/time
4. Date/time
5. Date/time
6. Date/time
7. Date/time
8. Date/time

Exams must be available or delivered to CSD a minimum of 24 hours in advance of test date.

Exam Pick-up Options:

• I will fax exam to CSD at (713) 743-5396.
• I will deliver exam to CSD.
• I will e-mail exam to CSD at uhcsd@mail.uh.edu.
• I request CSD to pick up exam from [provide location].

I understand that exams will be returned to my department location, by CSD, within 48 hours of completion.

Special instructions:

Student may use the following aids during this exam:

• Calculator
• Book
• Notes
• Other

• Instructor's signature
• Date
• Contact Person
• Building/Room
• Extension
• Fax

University of Houston
Justin Dart, Jr. Center for Students with DisABILITIES (CSD)
CSD Building, Room 100 (Building #568)
Houston, TX 77204-3022
Telephone: 713-743-5400
Fax: 713-743-5396
Mail Code: 3022
E-mail: uhcsd@mail.uh.edu
Web: www.uh.edu/csd
Hours: 8-5 Monday-Friday
Fall and Spring: 8-7 Monday and Tuesday