IASHEP Proctor Agreement Form

Thank you for your commitment in requesting to serve as a proctor for an International
Association of Safety, Health and environmental Professionals (IASHEP) student.
IASHEP Authorized Learning Partners and other Individuals assuming proctor
responsibilities should sign and submit the Proctor Agreement Form by fax: (520) 568-
5565. Alternatively, the form can be scanned and emailed to peggypodojil@iashep.org
Should you have questions before, during, or at the conclusion of the examination,
please call (520) 568-5565 or email peggypodojil@iashep.org.
STUDENT INFORMATION
Last Name ____________________________________________
First _________________________________________________
Member ID ____________________________________________
Phone ________________________________________________
Email: ________________________________________________
PROCTOR INFORMATION
Check this box if you intend to proctor for other IASHEP students than the one
listed above. You will not need to complete an additional Proctor Agreement.
Last Name ______________________________________________
First ___________________________________________________
Middle _________________________________________________
Title ___________________________________________________

Employer ___________________________________________________
Business Address ____________________________________________
City ________________________________________________________
State _______________________________________________________
Zip _________________________________________________________
Relationship to Student _________________________________________
Work Phone ( )_____________________________________________
Email _______________________________________________________
PROCTOR CERTIFICATION
The proctor must provide official certification or documentation verifying their position.
Certification should accompany this request, as it cannot be processed without the
adequate support documentation.
I hereby certify I meet the requirements of a IASHEP proctor. As an authorized exam
proctor, I agree to adhere to those responsibilities and procedures outlined in the Final
Examination Proctor Policy when administering Final Exams. Most importantly, by my
signature below, I attest that I will only allow the student to access his/her exam in my
presence and that I will remain in proximity during the taking of this exam. I will close
student access to the exam at the end of the four hours allotted. I also agree that
IASHEP may contact me for verification purposes and I grant permission for IASHEP to
verify my credentials.
Proctor Signature______________________________________________________
Date ________________________