Testing Incident Report Form 2017-2018 Hawaiʿi Statewide Assessment Program Testing Incident Report Form School: School Code: Today's Date: School Telephone Number: Test Coordinator Name: Person Completing this Report: Test Coordinator E-mail: Test Administrator Name: □ □ □ □ □ Severity Level: Impropriety Irregularity Breach Initiated by: Adult Student □ □ Assessment: Smarter Balanced ELA/Literacy CAT Smarter Balanced ELA/Literacy PT □ Smarter Balanced Mathematics CAT □ □ □ □ □ HSA Science Bridge Algebra 1 EOC Algebra 2 EOC Biology 1 EOC HSA-Alt □ ACCESS for ELLs Date/Time of Incident: Grade Level: Test Session ID: Description of Incident: Description of Action Taken: Adults Involved: Name Assessment Role Description of Involvement Action Taken Students Involved: SSID Description of Involvement Action Assessment Section Use Only Verified: Y or N Name and Date: Fax the completed form (and additional sheets as necessary) to the Assessment Section at (808) 733-4483; or, scan and send in an encrypted e-mail to (full Lotus Notes address required). The school Test Coordinator should retain the original form for documentation purposes.
Testing Incident Report Form 2017-2018 Hawaiʿi Statewide Assessment Program Testing Incident Report Form School: School Code: Today's Date: School Telephone Number: Test Coordinator Name: Person Completing this Report: Test Coordinator E-mail: Test Administrator Name: Severity Level: □ Impropriety □ Irregularity □ Breach Initiated by: □ Adult □ Student Assessment: □ Smarter Balanced ELA/Literacy CAT □ Smarter Balanced ELA/Literacy PT □ Smarter Balanced Mathematics CAT □ HSA Science Bridge □ Algebra 1 EOC □ Algebra 2 EOC □ Biology 1 EOC □ HSA-Alt □ ACCESS for ELLs Date/Time of Incident: Grade Level: Test Session ID: Description of Incident: Description of Action Taken: Adults Involved: Name Assessment Role Description of Involvement Action Taken Students Involved: SSID Description of Involvement Action Assessment Section Use Only Verified: Y or N Name and Date: Fax the completed form (and additional sheets as necessary) to the Assessment Section at (808) 733-4483; or, scan and send in an encrypted e-mail to (full Lotus Notes address required). The school Test Coordinator should retain the original form for documentation purposes.
2017-2018-Testing-Incident-Report-Form.docx