Application For Testing Accommodations - Form D

FORM D TESTING ACCOMMODATIONS ADD/ADHD 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 ______________________________________________________________ Please describe the credential(s) that qualify you to diagnose and/or verify the applicants condition and to recommend testing accommodations: Describe briefly the applicants current self-reported symptoms of ADD/ADHD: Are these symptoms secondary to ADD/ADHD? _______ Is there evidence of a comorbid psychiatric condition or a learning disability? _______ If YES, please describe: -1- Does the applicant have a documented history of childhood ADD/ADHD? _______ If YES, <<<<<<<<<********>>>>>>>>>>>>> 2describe psychological history, developmental history, educational history and developmental milestones. Attach a separate statement if necessary. If NO, what evidence has been presented to you for review (i.e., school records, parental interview, etc.) to support the applicants history of childhood ADD/ADHD? Please provide an evaluation of the applicants: * Overall cognitive ability * Academic ability * Processing ability Does the cognitive assessment support ADD/ADHD? _______ Briefly explain: Is the applicant being treated for ADD/ADHD? _______ If YES, describe: Does the condition substantially limit the applicants performance of a major life activity? _____ If YES, explain: How does the condition affect the applicants ability to complete the examination under standard conditions? -2- Is there any objective evidence that the requested accommodations facilitate the applicants test <<<<<<<<<********>>>>>>>>>>>>> 3performance? Fully explain: Based on the information above and petitioners condition and your diagnosis, what testing accommodations would you recommend? Explain how the recommended testing accommodations relate to the functional limitations associated with the condition and the basis for that 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, psychiatrist or other qualified specialist. Each case will be evaluated on its facts. 2000 -3-