Form PTO 158RA PTO 158RA Request for Reasonable Accommodation

Admission to Practice and Roster of Registered Patent Attorneys and Agents Admitted to Practice Before the United States Patent and Trademark Office (USPTO)

Aug_2011_PTO158RA_Draft_Form_0651-0012

Request for Reasonable Accommodation

OMB: 0651-0012

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VIII. REASONABLE ACCOMMODATION

A. REASONABLE ACCOMMODATIONS REQUESTS: A Request for Reasonable Accommodation package has been developed to facilitate an applicant’s request for reasonable accommodation due to a mental and/or physical medical condition to take the examination for registration to practice before the United States Patent and Trademark Office (also known as the registration examination). The Request for Reasonable Accommodation package consists of an Applicant’s Statement and a Licensed Health Care Professional’s Statement. If an applicant requests a reasonable accommodation to take the registration examination, then the applicant must complete this package. Failure to provide the requested information may result in the USPTO having insufficient information to grant the requested accommodation.

An applicant requesting reasonable accommodations should check the box to the right of his or her name in the Application for Registration (PTO Form 158), indicating that the request is included with the application.

After an applicant has been admitted to the examination, a separate notification of the

accommodations granted will be mailed.

i. An applicant admitted to the USPTO-administered examination will be given specific

information concerning the time and place of the administration of the examination.

ii. An applicant admitted to the commercially-administered examination is provided

additional time to schedule the examination with Prometric. Scheduling may take up to 30 days. An applicant granted admission to the commercially-administered examination, after receiving the noted reasonable accommodation from OED, must then call the Reasonable Accommodations Department in the Prometric Contact Center at 800-967-1139 to schedule administration of the examination. If reasonable accommodation is requested and the admission notice does not address the request, please contact OED.

B. Instructions For Completing the Reasonable Accommodations Package: An applicant should provide detailed responses to the questions in the Applicant's Statement. An applicant may use additional paper, if necessary, to answer the questions.

The applicant must also provide a completed Licensed Health Care Professional’s Statement and/or other acceptable medical evidence to support the claim.

The completed package should be submitted to the United States Patent and Trademark Office’s Office of Enrollment and Discipline with the completed Application Form 158. A Request for Reasonable Accommodation submitted separately from the Application Form 158 should be addressed to Mail Stop OED, Director of the U.S. Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450. For additional guidance you may contact the Office of Enrollment and Discipline at 571-272-4097.

C. REAPPLICATION: An applicant who received a reasonable accommodation(s) for a prior registration examination must submit a new Applicant’s Statement with each new Application for Registration (PTO Form 158). Depending on the type of impairment from which the applicant suffers, the applicant may want to submit a new Licensed Health Care Professional’s Statement as well. In deciding whether to submit a new Licensed Health Care Professional’s Statement, the applicant should consider that the Agency’s determination of both whether to grant an accommodation and what accommodation(s) is appropriate is based on an assessment of the current impact of the applicant’s disability on the testing activity. For example, if the applicant suffers from an impairment that is temporary or changes over time, it may not be possible for the Agency to assess whether an accommodation should be granted if the Licensed Health Care Professional’s Statement is not current. For chronic or long-term conditions, a new Licensed Health Care Professional’s Statement may not be necessary.

Form PTO 158RA (3/11)

OMB Control Number 0651-0012; Approved for use through xx/xx/20xx

Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

Request for Reasonable Accommodation

APPLICANT’S STATEMENT

Name of Applicant (last, first, middle): ______________________________________________
Applicant’s address:

Telephone: ______________________________________________________________
E-mail address: __________________________________________________________

Location of Exam: _______________________________________________________________
Date of Exam: __________________________________________________________________
Describe applicant’s medical condition(s) (i.e., illness, disease, or injury) and how it (they) interfere(s) with applicant’s ability to complete the registration examination in the standard time allotted and/or in the standard conditions.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide the date of the most recent evaluation of applicant’s disability: ____________________

Did applicant apply for and receive nonstandard testing accommodation for classroom examinations and/or admissions tests? □ yes □ no. If yes, (1) check all that apply (2) describe the specific accommodations, (3) specify amount of additional time received, and (4) if applicable, please note if accommodations were denied.

Accommodations Additional Time Granted Denied

□ Grade School ______________________ ________ _____

□ High School ______________________ ________ _____

□ College ______________________ ________ _____

□ Law School ______________________ ________ _____

□ SAT ______________________ ________ _____

□ LSAT ______________________ ________ _____

□ MPRE ______________________ ________ _____

□ GMAT ______________________ ________ _____

□ Other please specify______________________________________

□ None

Please provide supporting documentation for the accommodations received above.
If applicant was denied for any of the above, please explain and attach relevant documentation.

Has applicant previously applied to take a registration examination(s)? □Yes □No.
1. Did applicant request any accommodations? □ Yes □No.

If yes, complete the following and provide supporting documentation:

Date of Exam Accommodation Received

___________ ______________________

Describe specifically what accommodation(s) applicant thinks could be made so that the test results accurately reflect applicant’s knowledge of patent laws, rules and procedures rather than reflecting any impairment to applicant’s abilities from a disability. Note that any accommodation applicant requests must be supported by the Licensed Health Care Professional’s statement(s) applicant submits (e.g., if applicant requests twice the amount of time to take the exam, then one of the Licensed Health Care Professional statements applicant submits must indicate that applicant needs twice the amount of time to take the exam and explain why applicant needs twice the amount of time).

____________________________________________________________________________________

This collection of information is required by 35 U.S.C. 2(b)(2)(D) and 37 CFR 11.7. This information is used by the Office to process requests for reasonable accommodations due to medical conditions to take the examination for registration to practice before the United States Patent and Trademark Office (USPTO). The Office will keep the information on this form confidential to the extent allowed under the Freedom of Information Act (FOIA) and the Privacy Act. Response to this information collection is voluntary; however, if the applicant does not provide the requested information, the USPTO may not have sufficient information to provide the appropriate accommodation. This form, together with the Application for Registration (PTO-158) with which it must be submitted, is estimated to take 90 minutes to complete, including gathering, preparing, and submitting the completed application to the USPTO. Any comments on the amount of time the applicant requires to complete this information collection and/or suggestions for reducing the burden created by this collection should be sent to the Chief Information Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450. DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS. SEND THE FORM AND FEES TO: Mail Stop OED, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450.

Request for Reasonable Accommodation

APPLICANT'S STATEMENT

____________________________________________________________________________________

Privacy Act Statement and CERTIFICATION AND CONSENT BY the Applicant:

The USPTO will process requests for reasonable accommodation and, where appropriate, provide reasonable accommodations in a prompt, fair and efficient manner.

The Privacy Act of 1974 (P.L. 93-579) requires that applicant be given certain information in connection with the request for personal information solicited on the Request for Reasonable Accommodation forms. Accordingly, please be advised that (i) the authority for the collection of this information is 35 U.S.C. § 2(b)(2)(D) and Section 504 of the Rehabilitation Act, (ii) furnishing of the information solicited is voluntary, and (iii) the principal purpose for which the information will be used is to process requests for reasonable accommodation for the registration examination to practice before the United States Patent and Trademark Office (USPTO) in patent cases. If applicant does not furnish the requested information, the USPTO may not have the information necessary to grant applicant’s request for reasonable accommodation. Routine uses of the information applicant provides on these forms may include disclosure to USPTO staff or other authorized personnel who require access to this information in the performance of their duties in processing these requests.

Under the Rehabilitation Act, medical information obtained in connection with the reasonable accommodation process must be kept confidential. This means that all medical information, including information about functional limitations and reasonable accommodation needs that USPTO obtains in connection with a request for reasonable accommodation must be kept in files separate from the individual’s application file. The information provided by applicant will be used primarily to facilitate the processing of applicant’s request for accommodation. Only parties who need to know this information as necessary and appropriate to make a determination about applicant’s request for reasonable accommodation will have access to this information.

All records obtained or created during the processing of a request for reasonable accommodation, including medical records, will be kept in the applicant’s medical file and will be maintained in accordance with the Privacy Act and the requirements of 29 CFR Part 1611.

I hereby certify that all statements made above are true to the best of my knowledge and belief. I hereby give permission for the release of information about my medical condition(s) to authorized agency officials.

_______________________________ ______________ ____________________

Signature (do not print) Date Phone number

Request for Reasonable Accommodation

LICENSED HEALTH CARE PROFESSIONAL’S STATEMENT

Applicant seeks to take the examination for registration to practice in patent cases before the United States Patent and Trademark Office (USPTO). The registration examination consists of 100 multiple choice questions. The exam is split into a morning session of 3 hours and an afternoon session of 3 hours. Fifty questions are asked during each of those sessions. Applicant is asking the USPTO to alter how the exam is administered because he/she has a disability(ies) that prevents him/her from completing the exam in the allotted time and/or under the standard conditions. Applicant is required to submit medical documentation to demonstrate that he/she has a physical or mental impairment that substantially limits one or more of his major life activities and to support his/her request for a reasonable accommodation. The Office of Enrollment and Discipline (OED) at the USPTO has developed this Licensed Health Care Professional’s Statement to assist medical professionals in providing the type of information that OED needs to determine whether a reasonable accommodation is warranted.

Applicant is responsible for any costs incurred in connection with providing this documentation.

A new medical examination is not necessary if the Licensed Health Care Professional can provide current information from his/her records.

Enclose this completed Licensed Health Care Professional’s Statement and any attachments in a sealed envelope marked “CONFIDENTIAL MEDICAL RECORDS.” Send it to the address shown below. Alternatively, it may be given directly to the applicant for delivery to OED at the USPTO.

Address to which Licensed Health Care Professional can mail statement:

U. S. Patent and Trademark Office

Mail Stop OED

Director of the US Patent and Trademark Office

PO Box 1450

Alexandria, VA 22313-1450

FAX: (571) 273-0154

Please complete this statement within 2 weeks. Please note that illegible or incomplete statements will not be accepted. Furthermore, additional sheets and reports may be attached, if necessary, to fully respond to any questions. Incomplete answers may result in the rejection of this statement and ultimately the applicant’s request for a reasonable accommodation.

Applicant's Consent to Release Medical Information.

I authorize the release to the United States Patent and Trademark Office of any and all information or records connected with my physical/mental impairment(s) (illness, disease, or injury) which are the basis of my Request for Reasonable Accommodation.

___________________________________ __________________

Applicant’s signature (do not print) Date

_________________________________

Applicant’s name (type or print)

Patient’s:
1. Name: __________________________________________
2. Address: __________________________________________

__________________________________________

Licensed Health Care Professional completing this form:
1. Name: __________________________________________
2. Profession: __________________________________________
3. Office address: __________________________________________

__________________________________________

Telephone number: __________________________________________
E-mail address: __________________________________________

Please provide a full explanation of your qualifications to submit this statement (include relevant education, certifications, licenses and professional history):

______________________________________________________________________________

___________________ was my patient from ______________ to _________________ and (□ did □ did not) become my patient, in part, for the purpose of procuring a report to be submitted to obtain nonstandard testing accommodations for taking of an examination.
My specific diagnosis (ICD 9 code and/or DSM IV code) for the patient’s condition(s) or illness creating a disability is as follows:

A full explanation of the basis for my diagnosis is as follows:

The specific and detailed nature and extent of the disability:
1. Is the applicant substantially limited in a major life activity? □ yes □ no
2. If yes, state what activities are affected:

The applicant’s illness or condition is: □ permanent □ temporary (check one).
1. If temporary, the disability will terminate on ___________________________________
The date of the onset of the patient’s illness or condition was _____________________________
I last examined the patient on _______________________________________________________
Test(s) administered and dates thereof:

Copies of the test results and reports concerning the tests are attached hereto: □ yes □ no
If such copies are not attached, the reason for their absence is:

In the case of ADHD:
1. Did the applicant have a previously documented history of ADHD at the time of your evaluation? □ yes □ no. If yes, briefly describe below. If no, what objective evidence has been presented for your review that supports a likely history of undiagnosed ADHD (e.g., school records and previous psychological tests)?

Does the applicant exhibit clinically significant impairment across multiple life domains (e.g., academic, work, social, etc.)? □ yes □ no. If yes, briefly describe:

My treatment of the applicant consists of:

As a result of my examination, tests and treatment of the patient, I have made the following findings and conclusions:
1. Presenting complaints:

Objective findings:

In your medical opinion, what accommodations would you recommend that your patient receive to be able to have the results of the registration examination accurately reflect his/her knowledge of patent laws, rules and procedures, rather than any impairment that results from his/her disability? Examples of accommodations USPTO has given in the past are an exam with larger font, additional time, a separate testing room from the main testing room, and additional lighting.

Provide a full description of the basis for the recommended nonstandard testing accommodations:

I declare under penalty of perjury that the above information is true and correct to the best of my knowledge.

Executed on ________________________ at ____________________________

(Date) (City and State)

By ______________________________________________________________

(Signature)

_________________________________________________________________

Type or Print Name (State License Number)

File Type	application/msword
File Title	Request for Reasonable Accommodation
Author	Goud P. Maragani
Last Modified By	USPTO
File Modified	2011-08-02
File Created	2011-08-02