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QAI14004
SECURE MATERIAL TRANSFER FORM
Arkansas Comprehensive Testing,
Assessment, and Accountability Program
Examination:
District LEA #:
Name of District Transferring:
No. of
Documents
Transferred:
Security ID Number(s) Transferred:
Signature of Sender:
Date:
Examination:
District LEA #:
Name of District Receiving:
No. of
Documents
Received:
Security ID Number(s) Received:
Signature of Receiver:
Date:
Instructions: Each district shall retain a copy of this form. A copy shall be faxed to the ADE Ofce of Student Assessment at (501) 682-4886 and to Questar
Arkansas Customer Service at (866) 688-0419. This form must be completed and signed by both districts before it is faxed. Both districts must staple a copy of
this Secure Material Transfer Form to the appropriate school’s Test Booklet or Test Administration Manual Security Form(s). If transferring materials within your
district, you do not need to complete this form and submit to ADE and QAI. However, it’s recommended it be completed for your records.