Reasonable Accommodation Request For Examinees With Disabilities
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2REASONABLE ACCOMMODATION REQUEST
FOR EXAMINEES WITH DISABILITIES
Submit the following with this application:
RETURN APPLICATION TO:
1. Current documentation from a doctor, psychologist, psychiatrist or
other appropriate professional certifying your disability.
Continental Testing Service
2. Documentation of special services and testing accommodations
P.O. Box 100
you received in school because of your disability.
LaGrange, IL 60525
3. A letter describing your specific disability, when and how it was first
identified and accommodations you are requesting because of it.
I.
DISABILITY STATUS (check all that apply)
A.
Are you:
deaf?
blind?
hard of hearing?
visually impaired?
B.
Do you have a:
Physical disability?
Please explain. ____________________________________________________________________
Specific learning disability?
Please explain. ____________________________________________________________________
Psychological disability?
Please explain. ____________________________________________________________________
C.
How long have you had your disability?
Most of my life
1 year
2 years
3 years
4 years
5 years or more
II. PAST ACCOMMODATIONS MADE FOR YOUR DISABILITY
A.
In high school:
Were you in a special school or program?
Yes
No
Did you get special accommodations for classroom tests?
Yes
No
Did you generally get extra time for classroom tests?
Yes
No
B.
Did you have special accommodations for taking the SAT or
Yes
No
ACT examinations for admission to college?
C.
In college:
Did you use disabled student services?
Yes
No
Did you generally get extra time for exams?
Yes
No
D.
Did you have special accommodations for examinations.
Yes
No
If yes, what accommodations? (Check all that apply)
Time:
Help:
Extra breaks/rest periods
Reader
Extra testing time
Recorder (scribe)
Other (Please explain) ______________________________
Sign language interpreter
III. CERTIFYING STATEMENT
I certify the above statements to be true.
Date
Applicant Signature
IL486-1766B 02/06 (TS)
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