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Form Doh 668-080 - Professional Evaluator Form For Applicant'S Disability-Based Accommodation For Examination(S) Page 2

3. What is the nature and extent of the disability (diabetic, dyslexia, hearing impaired or vision)?

Does the disability limit one or more of the applicant’s major life activities, and will the

disability change in any way over time? Does the disability impair the applicant’s ability to

take either of the exams required? Include objective data in your analysis.

__________________________________________________________________________

4. How did you arrive at your diagnosis (clinical interview, record review, psychological, or

neuropsychological assessment)? Please attach documentation to support your diagnosis.

__________________________________________________________________________

5. What is the effect(s), if any, of any disability you have assessed on the applicant’s ability

to perform under normal testing conditions? Please see our

website

for examination

information.

__________________________________________________________________________

6. If applicable, what is the recommended accommodation? Identify each examination that the

accommodation is being recommended for.

____ Additional 30 minutes of time

____ Large-type exam and answer sheet

____ Time and a half

____ Additional rest breaks

____ Double-time

____ Scribe

____ Separate room

____ Audio recording of exam

____ Reader

____ Sign Language Interpreter

____ Other ________________________________________________________________

DOH 668-080 April 2013

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Form Doh 668-080 - Professional Evaluator Form For Applicant'S Disability-Based Accommodation For Examination(S) Page 2