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OSA Security Compliance Form I the undersigned do certify and attest to all of the following understand that all assessment items are considered secure and may not be copied photographed or I communicated in any way. have had access to a printed or electronic copy of the Assessment Integrity Guide as published by the Office of Standards and Assessment OSA of the Michigan Department of Education MDE and I have read the sections applicable to assessment security preparation and administration and I have followed the practices found in the current assessment manual s as they relate to my role. Date School Year Signature Printed Name Note Electronic copies of the Assessment Integrity Guide and assessment administrator manuals are available at www. michigan*gov/baa* For further information contact the Michigan Department of Education Office of Standards and Assessment OSA 608 W* Allegan St* P. O. Box 30008 Lansing MI 48909 call toll-free 877 560-8378 or e-mail baa michigan*gov* 1. Assessment Roles Mark ALL that apply n District Coordinator or Technology Coordinator n Proctor n Item Writer n School Coordinator Test Supervisor or Back-Up Test Supervisor n School Administrator n Context Writer n Accommodations Provider or Test Accommodations Coordinator n District Administrator n Expert Reviewer n Assessment Administrator or Room Supervisor n Committee Member n Other 2. Educational Entity PLEASE PRINT Use full names School Name School Code District Name District Code TO COMPLETE Directions 1. Mark the corresponding box es next to the assessment program s for which you have one or more roles. M 3. n the area under Educational Entity district coordinators print district name only. All others print both district name and school name on the lines provided* If known please provide school and district codes. IMPORTANT Districts must keep all completed Security Compliance Forms current and on file at their district for a period of one year following the assessment window. have had access to a printed or electronic copy of the Assessment Integrity Guide as published by the Office of Standards and Assessment OSA of the Michigan Department of Education MDE and I have read the sections applicable to assessment security preparation and administration and I have followed the practices found in the current assessment manual s as they relate to my role. Date School Year Signature Printed Name Note Electronic copies of the Assessment Integrity Guide and assessment administrator manuals are available at www. Date School Year Signature Printed Name Note Electronic copies of the Assessment Integrity Guide and assessment administrator manuals are available at www. michigan*gov/baa* For further information contact the Michigan Department of Education Office of Standards and Assessment OSA 608 W* Allegan St* P. michigan*gov/baa* For further information contact the Michigan Department of Education Office of Standards and Assessment OSA 608 W* Allegan St* P. O. Box 30008 Lansing MI 48909 call toll-free 877 560-8378 or e-mail baa michigan*gov* 1. Assessment Roles Mark ALL that apply n District Coordinator or Technology Coordinator n Proctor n Item Writer n School Coordinator Test Supervisor or Back-Up Test Supervisor n School Administrator n Context Writer n Accommodations Provider or Test Accommodations Coordinator n District Administrator n Expert Reviewer n Assessment Administrator or Room Supervisor n Committee Member n Other 2.

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