Application For Testing Accommodations - Form C

FORM C TESTING ACCOMMODATIONS LEARNING 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 ____________________________________________________ List your academic and professional credentials allowing you to diagnose this applicants condition: Dates of tests or evaluations and treatment __________________________________________ Last date of treatment/consultation with applicant ______________________________________ Summary of diagnosis: Briefly describe the nature of the condition and how this condition affects the applicants ability to take the examination (i.e., functional limitations): -1- Briefly describe your treatment of this condition: <<<<<<<<<********>>>>>>>>>>>>> 2 Briefly describe whether this treatment has been effective: Is this a permanent condition that substantially limits the applicants performance of a major life activity? _______ If NO, when is the condition likely to abate? Specify how this condition limits the activities of the applicant, educationally and psychologically, with regard to the examination: In what way does the condition affect the applicants ability to read, write, process information or concentrate for the examination? 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. -2- Explain how the recommended testing accommodations relate to the functional limitations <<<<<<<<<********>>>>>>>>>>>>> 3associated 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? Attach the following reports: 1. A review of the assessment process, administered within the last three years, identifying the applicants learning disability, which includes an interpretation of data from both cognitive and achievement measures. List tests administered. 2. Background information including: a. How the applicants disability presents itself b. History of the disability c. Relevant family history d. Functional limits the disability imposes (occupationally, socially, psychologically) e. Remediation attempted and its results f. Psycho-social history g. Developmental milestones h. Diagnosis Without these reports, the petition will be considered incomplete. Clinician/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 Clinician/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, psychiatrist or other qualified specialist. Each case will be evaluated on its facts. 2000 -3-