Application For Disability Accommodations printable pdf download

INSTRUCTIONS

APPLICATION FOR DISABILITY ACCOMMODATIONS

The Application for Disability Accommodations is to help the social work board in your jurisdiction determine

(1) whether you are a qualified disabled individual under applicable federal, state, provincial, or local legislation

and (2) whether the accommodation you are requesting is reasonable. Consideration of all requests will be made

under applicable laws.

PART I: The information requested on Part I of the form is self-explanatory. You are not required to furnish

your Social Security Number (US)/Social Insurance Number (Canada), but this information would be most

helpful in identifying you and relating this Application for Disability Accommodations to other parts of your

examination application. After you have completed Part I, the application must be dated and signed by you and

notarized by a Notary Public in your jurisdiction. ALL APPLICATIONS MUST BE SUBMITTED WITH

ORIGINAL SIGNATURES. COPIES OR FAXED SIGNATURES WILL NOT BE ACCEPTED.

PART II: Part II of this Application for Disability Accommodations should be completed by your health care

practitioner or other appropriate professional and signed and dated where indicated. ALL APPLICATIONS

MUST BE SUBMITTED WITH ORIGINAL SIGNATURES. COPIES OR FAXED SIGNATURES WILL

NOT BE ACCEPTED.

SUBMISSION OF THE FORM: The ASWB examinations are offered through the relevant jurisdictional board.

Although each board’s application process may differ slightly, this form must be submitted before the board can

make a decision on any examination accommodations requested. Parts I and II of this Application for Disability

Accommodations should be mailed directly to ASWB at the address below.

You must receive approval from your board and ASWB before registering for an examination. Forms not

fully completed will be returned to the applicant.

Please consult with your board to determine the appropriate application process and relevant deadlines.

A submitted Application for Disability Accommodations will remain valid for one year from the date when

executed by the applicant. A valid application will be considered for any examination occurring within this one-

year period provided the applicant makes a request at the time of registration.

Under any circumstances, it is recommended that you maintain a copy of this form for your records. Questions

may be directed to your board or to ASWB (1-800-225-6880, extension 3024).

SUBMIT PARTS I AND II OF THE APPLICATION FOR DISABILITY ACCOMMODATIONS

AT THE SAME TIME

Applications for Disability Accommodations should be mailed to:

ASWB Candidate Services

P.O. Box 1508

Culpeper, VA 22701

ASWB Social Work Licensing Examination

Revised 2015

Application For Disability Accommodations