ADA Packet

Thomson Prometric strives to provide an equal testing opportunity for all candidates. The purpose of any
special accommodation is to ensure that the examination results reflect a candidate's aptitude or other
factor that the exam is designed to measure, rather than reflecting the candidate's sensory, manual or
psychological skills (except where those skills arc factors the exam is designed to measure).
We ask all candidates requesting an accommodation to take the time to carefully complete this packet
before submitting their rcqucst. A completed Accommodation Request Packet includes the Candidate
Accornrnodatjon Request Form, the Professional Evaluation Form and any additional verification
required. A complete packet will allow Thomson Prometric to assist the candidate in arranging the best
accommodation possible for the situation. We are unable to process incomplete Accommodation
Requests.
Completed Accommodation Request Puckets will be re~ieweclwithin 5 to 7 business duys and will be kept
cottfidentiai. Accommodutions will be urrunged us quickly as possible and at no extra charge to the
candidate.

Our Special Accommodation Registrars are here to help you. Please contact us to answer any questions
or concerns about who signs where, or what type of accommodation would work best for you or to simply
walk you through the request process.
To help you in your request, Please keep the following in mind as you complete this packet:
1.

All test sites are wheelchair accessible - No request is rcquired.

2.

You MUST either have an appropriate professional (an internist, for example, is not appropriate to
diagnosc a mental disorder or reading disability) complete the Professional Evaluation Form OR
provide existing documentation from the person(s) who granted you the same or similar
accommodation you are now requesting in another formal testing environment (the Professlional
Evuluution Form must still be returned with the appropriate box marked).

3.

We can NOT make any accommodations of a "personal nature" (lifting or feeding, for example).

4.

If you choose to provide existing documentation of a similar accommodation, you may be required
to provide additional verification.

CANDIDATE ACCOMMODATION REQUEST FORM

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Candidate Name:
ID Number (usually SS#):
Address:

- ...---

City, State, ZIP:
Daytime Phone Number:
Fax Number:

Other Number:

E-Mail:

Name and Number of the Exam(s) Requested:

Exam Site Requested:
Earliest Date You Are Available to Test:
Disability:
Additional Testing Time

Thirty minutes
50% (time and one-hag
100% (double tinrej

Assistance

Reuder
Recorder of uns tt0c1,-s
Sign Languuge Irtterprtlter
(for spoken directions only)

Other (please specify)
Additional Comments (For example: "Will need to bring a nurse assistant."):

PLEASE READ AND SIGN:

I authorize release of the altached f o m ~ sto Thornson Prometric staff to review and arrange the requested
accommodation.
1 give m y pennission for m y diagnosing professional to discuss with Thomson Prometric staff my records
and history in a s much as they relate to the requested or suggested accommodation.

I understand and agree that Thomson Prometric staff may provide my records to an appropriate
professional selected by Thomson Prometric for an independent evaluation relating to my request or to the
state or local agency for which the exam is administered.
1 understand that i f 1 choose to provide existing documentation of the same or a similar accommodation, I
may be required to provicle additional verification, including completion of the Professional Evaluation

Form.

Signature:

Date:

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*
THOMSON

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PROMETRIC

PROFESSIONAL EVALUATION FORM
To the Professional:
By submitting this form with your signature and license number listed, you are verifying that you have
formally diagnosed the candidate named on this form as having the disability documented below or, in
your professional capacity, you have worked with the candidate in dealing with the disability documented
on the following page. You further verify that the accommodation you recommend is necessary to fairly
demonstrate the candidate's ability in a liccnsure exam.

The purpose of any special accommodation is to ensure that the examination results rcjlect u candidate 's
uplitude or other factor thal the exam is designed to measure, rather than reflecting the candidate *s
sensory, mmanual or psychological skills (except where those skills are factors the exum is designed to
measure). Our intent is to provide equal opportunity for all candidates. The accommodation must not
unfairly advantuge or disadvunfuge the candidate.
Please call us if you have any questions regarding the exam or response format, physical environment,
required documentation or determination of appropriate and reasonable accommodations. For example,
while a reader or scribe is a reasonable accommodation, providing a written paper exam for a computerbased test' or a computer-based test for a written paper exam is a VERY difficult request to honor and is
generally not considered reasonable. Finally, Thomson Prometric is unable to accommodate a request for
"unlimited time." If extra time is needed, please specify the amount.
Exam Candidate Name:
Professional (Please Print your Name):
Address:
City, State, ZIP:
Phone Number:
E-Mail:

Fax Number:

License Number:
Board Certification:

State of Licensure:

Signature of Professional:

* Candidate's

Date:

diagnosis and your recommendation on back page (Attach additional pages if needed.)

0 Provide existing documentation from person(s) who granted same or
similar accommodation in another formal testing environment.

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PROFESSIONAL EVALUATION
To Be Completed Only By A Licensed Professional
Esam Candidate Name:
Diagnosis: (Note: mental and cmotiot~aldisabilities must include diamosjs code from DSM-111-R or
DSM-IV.)

I have known

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.

(candidutc) since
(dute) in my capacity
The c z ~ d i d a t ehas heen diagnosed with the following disability:

The candidate or Thomson Prometric staff has discussed with me the nature of the test to be administered.
It is my opinion that because of the candidate's disability, the candidate should be accommodated by
Thomson Prometnc providirig the following:

Signature of Professional:

Date:

Name (ptij~ted):

Title:

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