CDME Exam Request Form

Exam Request Form

Which exam would you like to schedule?*
- Aquifer Internal Medicine Clinical Decision-Making Exam (formerly Key Features Exam)
What is the name of your school?*
Please contact exams@aquifer.org if your school is not listed here.
Your Official Program Name
ie. Case Western Reserve University Physician Assistant Program
How do you plan to proctor your exam?*
- In-person proctoring
- Video proctoring
Desired start date for your exam:*
If this exam needs to stay open for more than 24 hours or will be taken by students at multiple locations please note that at the bottom of this exam request form.
MM slash DD slash YYYY
How many students will be taking this exam?*
Desired start time for your exam (Eastern Standard Time)*

: Hours

Minutes

AM/PM
Do any of your students require additional time to complete the exam?
Pediatrics = 2.5 hours Family Medicine = 3 hours Internal Medicine = 1.15 hours Radiology = 2 hours
- Yes
- No
Please list students requiring additional time, and let us know how much time is needed:
Student Name Student Email Extra Time Needed (1.5x or 2x)
What is the purpose of the exam?*
- Pre-test
- Practice (mid-rotation)
- NBME preparation (mid-rotation)
- Mid-term
- NBME preparation (end of rotation)
- Final
- Re-take / Remediation
- Residency use
What type of students will be taking the exam?*
- 1st year medical students
- 2nd year medical students
- 3rd year medical students
- 4th year medical students
- Osteopathic medicine students
- Nursing students
- PA students
- Resident user
- Other
What type of computers will be used for this exam administration?*
- Institutionally owned computers (lab/library)
- Institutionally owned computer (assigned laptop)
- Student owned personal computer
Primary Contact for this Exam*
First Last
Primary Contact Email*
Phone number where the primary contact may be reached on the day of the exam:*
Please upload your exam roster here.
If you have any issues with your upload, please email your roster directly to exams@aquifer.org.
Drop files here or

Max. file size: 256 MB.
Please note any special circumstances or requests below:
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Name

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Comments

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Phone

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Phone

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Name

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

First Name*

Last Name*

Email*

Enter Email Confirm Email

Program/School Name*

Phone

School Name*

Anticipated start date*

Date when you want to start your subscription

Program type:*

I'm interested in:

Accessing a demo case

Scheduling a full demo

Pricing information

Comments or questions:

Phone

This field is for validation purposes and should be left unchanged.

Student Name	Student Email	Extra Time Needed (1.5x or 2x)

Exam Request Form

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