Application For Testing Accommodations - Form B

FORM B TESTING ACCOMMODATIONS PHYSICAL DISABILITY VERIFICATION To be completed by a physician/licensed professional (Please print or type) Name of applicant requesting testing accommodations __________________________________ Name of physician/licensed professional _____________________________________________ Address ______________________________________________________________________ Street Address or P.O. Box Number _____________________________________________________________________________ City, State and Zip Code Telephone Number _______________________________ Title and Specialty ______________________________________________________________ Name of Applicants Disability _____________________________________________________ Briefly describe the nature and extent of each impairment of applicant and provide supporting documents: How does the impairment affect specific areas of functioning? Give examples: Does the condition substantially limit the applicants performance of a major life activity? ____ If YES, explain. Is this a permanent condition? _______ If NO, when is the condition likely to abate? -1- In what way(s) does the condition affect the applicants ability to take the examination under <<<<<<<<<********>>>>>>>>>>>>> 2standard testing conditions? Based on the information above, on the applicants condition and your diagnosis, what testing accommodations would you recommend for taking the examination? Describe below all accommodations you believe are necessary, giving reasons and basis. Explain how the recommended testing accommodations relate to the functional limitations associated with the disability and the basis for the determination. Give specific examples. Are there any corrective measures that would improve the applicants ability to take the examination under standard testing conditions? If so, what are those measures? Physician/Licensed Professionals Signature I declare under penalty of perjury under the laws of the State of Iowa that the above information is true and correct. ____________________________________ __________________ _______________ Signature of Physician/Licensed Professional License/Certification No. Date The Board of Law Examiners reserves the right to make a final judgment concerning testing accommodations and may, in its discretion, seek an independent evaluation from a medical specialist, psychologist or other qualified specialist. Each case will be evaluated on its facts. 2000 -2-