Excess Assessment Approval Form
All 5th or beyond attempts are submitted by Senior Program Managers to the Associate Provost for Academic Services

Student Name | Ric Johnson | Student ID # | 467966 | Mentor Name | David Moll | Assessment | QRT2 | Assessment Code | QRT Task 1 |

STUDENT PORTION OF FORM Student, please complete the sections below related to your attempt request. Please type name and date at end of form after completing your portion. |

Do you have all available learning resources (check the course of study for confirmation)? | YES or NO If NO, please explain | Please list the specific textbooks and any other resources you used to prepare for this assessment. | | How did you use the competencies/topics from the coaching reports and/or scoring notes to your preparation for this attempt? | | How have you used the learning communities to gain competence related to this assessment? | | Please use this portion of the form to explain what you have done to prepare to retake/resubmit this assessment including what you have done to prepare for this attempt that you have not done in the past. Be as detailed as possible. | |
After completion of your section above, please email this form to your student mentor for approval.

COURSE MENTOR PORTION OF FORM Course Mentor, please complete the sections below related to the student’s attempt request. Please type name and date at end of form after completing your portion. |

Has this student worked with you to prepare for this and/or previous attempts? Please provide dates and details of contact. | | Do you agree that the student is ready for this assessment attempt? Please provide details if necessary. | |
After completion of your section above, please email this form to the student mentor.

STUDENT MENTOR PORTION OF FORM Mentor, please complete all sections below related to the student’s attempt request. Please type name and date at end of form after completing your portion. |

Pre-assessment Pass Date and Score (For Objective Assessment Attempts)
State the dates and number of attempts. Please note: a passing score on the pre-assessment within the past 30 days is required if possible. Not applicable if there is no accompanying pre-assessment. Attempt # | Date of Attempt | Score of Attempt | Attempt 1 | | | Attempt 2 | | | Attempt 3 | | | Attempt 4/Other | | |
Assessment Dates and Scores
State the dates and number of attempts/re-submissions. Attempt # | Date of Attempt | Score of Attempt | Attempt 1 | 5/18/2012 | Needs Revision | Attempt 2 | 5/30/2012 | Needs Revision | Attempt 3 | 6/28/2012 | Needs Revision | Attempt 4/Other | | |

For any attempt past number 3, please provide specific details of assessment attempt history including items such as LR engagement, CM contact, additional ‘outside’ assistance, etc. | |

Has the student completed all modules in the Course of Study? | YES | Has the student worked with a tutor? Please provide details. | No, Course Mentor only | Please attach and send all engagement reports, relevant to the assessment in question, to the appropriate Manager. | Not attached, not applicable |

TYPED NAMES AND DATES Each person who completes a portion of this form should enter their name and date of completion in the table below. |

ROLE | NAME | DATE | Student | | | Student Mentor | David Moll | 7/6/2012 | Course Mentor | | | Program Manager (Objective Exams - Attempt 3; Performance Tasks - Attempt 4) | | | Senior Program Manager (Objective Exams - Attempt 4; Performance Tasks - Attempt 5) | | | Note: All 5th or beyond attempts are submitted by Senior Program Managers to the Associate Provost for Academic Services