Form Doh 668-080 - Professional Evaluator Form For Applicant'S Disability-Based Accommodation For Examination(S)

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Psychology Program
PO Box 47877
Olympia WA 98504-7877
360-236-4700
Professional evaluator form for applicant’s
disability-based accommodation for examination(s)
Please print or type clearly in blue or black ink.
Do not reference any separate report for the answers to the questions listed below. This form must be
completed in order for the applicant’s request to be considered.
Review the board’s
policies and procedures
for disability-based examination accommodation
requests before you complete this form. The applicant must notify the board of the examination(s) that
they are requesting a disability-based accommodation. The following are the examinations available:
• The Examination for Professional Practice in Psychology (EPPP) is a national examination
administered by Prometric Examination Services (PES).
• The jurisprudence examination is developed by the board and administered by the
Department of Health.
The applicant must complete both examinations prior to licensure, see
WAC
246-924-070. The
policies and procedures
include information about the requirements for a disability determination,
including:
• Applicable definitions of “disability” under the Americans with Disabilities Act (ADA);
• Washington Law Against Discrimination (WLAD).
_________________________________________________ ___________________________
Applicants name:
Applicants Date of Birth (mm/dd/yyyy)
1. State the credentials and experience that qualify you to make the determination of any
disability related to the applicant’s request for an accommodation to take the EPPP and/or the
board’s jurisprudence examination, and to make any recommendation for an accommodation.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. What is the type of disability that limits one or more of the applicant’s major life activities
(physical, mental, or learning)?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
DOH 668-080 April 2013
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