NYSED Test Security Incident Form

Test Security Incident Report Form

In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), please do not include any confidential or personally identifiable information regarding students when submitting this incident report form. Initials only should be used for student names.

Contact Information

What is your first name?

What is your last name?

What is your phone number?

Valid formats are: (###)###-### or ###-###-####

What is your email address?

Must be a valid email using a .com or .edu domain

What is your position?

Allegation and Incident Location

Incident Details

Include: A detailed description of a) what happened b) on what date c) who was involved d) how you learned about it and e) any others who know about or witnessed the incident. Please use initials for first and last names of any student discussed. (2,000 character limit)

Name of Person(s) involved in incident:

Use the individuals' initials separated by commas

Name of School District/BOCES

School Name

State Exams Affected

Which Exams were affected?

Was the administration of the exam(s) paper-based or computer-based?

School year of Exam Administration

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​Test Security Incident Report Form

Contact Information

Allegation and Incident Location

State Exams Affected

Test Security Incident Report Form