Fcb Accommodation Request Form printable pdf download

Fcb Accommodation Request Form

FCB Accommodation Request Form

Candidates requesting reasonable testing accommodations must complete this form, attach all

appropriate documentation, and submit it with the request to sit for the examination. The

information below is considered confidential and will not be shared with outside sources without

your written consent.

Name: _________________________________________________________________________________

Phone #: (_______) ___________________________

SSN#: _________________________________

Disability (check all that apply):

Visual Impairment

Hearing Impairment

Learning Disability

Writing Disability

Health Impairment

Orthopedic Impairment

Mental/Emotional Impairment

Other (specify)

Accommodations Requested:

Accessible Test Site

Large Print (where available)

Reader for Visual Impairment

Scribe for Motor Impairment

Reader for Learning Disability

Scribe for Learning Disability

Sign Language Interpreter

Extended Time

Other (specify)

Name/Title of professional who diagnosed your disability: __________________________________

Date Diagnosed: __________________

* If request for accommodation is due to religious reasons, please provide documentation (signed

statement) from clergy.

Some accommodation requests may require additional documentation (see reverse side)

Fcb Accommodation Request Form