Testing Irregularity Statement
DIRECTIONS: This report must be completed by each individual involved in the testing incident on the day of the testing incident before leaving campus. If an irregularity is discovered after testing, this report must be completed as soon as the discovery is made. A copy will be provided to you after submission; a copy of the submitted form must be emailed to the campus CTC.

If you need assistance completing this form, ask your Campus Test Coordinators for help.

If you have questions you can also contact your District Testing Coordinators:

Blake Emmons  Pasadena ISD Extension 78154  713-740-5250 (direct office line)  
Amy Duke  Pasadena ISD Extension 78150  713-740-5246 (direct office line)
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Email *
Campus *
Date *
MM
/
DD
/
YYYY
Time *
Time
:
Campus Incident # (CTC will provide this to all individuals submitting a Testing Irregularity Statement form; see your CTC immediately before proceeding with this form if you do not have the Campus Incident #)
Campus Testing Coordinators Name *
Name *
Phone Number *
Position *
Role During Testing *
Test Administration *
Test *
Grade Level *
Subject Area *
Score Code gridded for each test involved *
Describe WHAT occurred. List the sequence of events in the order in which they occurred. Include all portions of the incident that involved YOU. Be specific - include time/dates. *
Describe WHEN the irregularity occurred, for example, while students were testing, during testing after returning from break/lunch, during testing when the student was taking a restroom break, etc.  Be specific. *
Describe WHY the irregularity occurred, for example, secure test materials were not monitored, students were not monitored, untrained testing personnel were in a testing area or with secure test materials, etc.  Be specific. *
List the action steps you will take to prevent this type of incident from occurring in FUTURE test administrations.  Do NOT describe what was done to address the current incident.  Be specific. *
Signature: By typing your name below, you affirm that all information presented in this document is true.  Your typed name indicates that you approve the authenticity of the information in the document, and the information presented is as complete as possible at the time the document is transmitted to the appropriate person(s) at your campus and/or to the Pasadena ISD Student Assessment Department. *
A copy of your responses will be emailed to the address you provided.
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