PTO-158RA Request for reasonable accommodation

OMB No. 0651‐0012 | Approved through x/xx/xxxx | FORM PTO‐158RA

U.S. PATENT AND TRADEMARK OFFICE

REQUEST FOR REASONABLE ACCOMMODATION
APPLICANT’S STATEMENT
1. NAME OF APPLICANT

Last Name

First Name

Middle Name

 Mr.  Ms.
1a. APPLICANT’S ADDRESS (street, bldg., suite, etc.)

1b. E-MAIL ADDRESS

1c. PHONE NUMBER

2. LOCATION OF EXAM

3. DATE OF EXAM

4. 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
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

5. Please provide the date of the most recent evaluation of applicant’s disability

______________________________________________________________________________________________________________
6. 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
□

Grade School

□

High School

□

College

□

Law School

□

SAT

□

LSAT

□

MPRE

□

GMAT

□

Bar Exam

□

Other

□

None

ADDITIONAL TIME GRANTED

please specify:

6a. Please provide supporting documentation for the accommodations received above.

DENIED

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

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6b. If applicant was denied for any of the above, please explain and attach relevant documentation.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

7. Has applicant previously applied to take a registration examination(s)?
7a. Did applicant request any accommodations?

□ YES □ NO

□ YES □ NO

IF YES, complete the following and provide supporting documentation:

Date of Exam

Accommodation Received

8. 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 grant applicant’s request for reasonable 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.

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

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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), 5 U.S.C. § 552a(e)(3), 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 and
administering an accommodation to applicant.
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.

________________________________________

_____________________

Applicant’s signature (do not print)

Date

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

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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)

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

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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/her
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) 273-4097
E-mail: OED Reasonable [email protected]

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.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II
from requesting or requiring genetic information of an individual or family member of the individual, except as specifically
allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to
this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history,
the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member
sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member
or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

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1a. PATIENT’S NAME

Last Name

First Name

Middle Name

 Mr.  Ms.
1b. PATIENT’S ADDRESS (street, bldg., suite, etc.)

2. LICENSED HEALTH CARE PROFESSIONAL COMPLETING THIS FORM:
2a. NAME

2b. PROFESSION:

2c. OFFICE ADDRESS:

2d. TELEPHONE NUMBER:

2e. E-MAIL ADDRESS:

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

4. _________________________________________________ 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.

5. 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:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

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

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

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7. The specific and detailed nature and extent of the disability:
7a. Is the applicant substantially limited in a major life activity? □ YES □ NO
7b. IF YES, state what activities are affected:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

8. The applicant’s illness or condition is:

□

permanent

□ temporary (check one)

8a. If temporary, the disability will terminate on ___________________________________________________________
9. The date of the onset of the patient’s illness or condition was __________________________________________________
10. I last examined the patient on ____________________________________________________________________________
11. Test(s) administered and dates thereof:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

12. Copies of the test results and reports concerning the tests are attached hereto:

□ YES □ NO

13. If such copies are not attached, the reason for their absence is:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

14. In the case of ADHD:
14a. Did the applicant have a previously documented history of ADHD at the time of your evaluation? □ YES

□ NO.

Page 8 of 9

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

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)?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
14b. Does the applicant exhibit clinically significant impairment across multiple life domains (e.g., academic, work, social, etc.)?

□ YES □ NO.
IF YES, briefly describe:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

15. My treatment of the applicant consists of:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

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

Page 9 of 9

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158RA

17. 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.

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

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

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

I hereby declare that all statements made herein of my own knowledge are true and that all statements made on information
and belief are believed to be true; and further that these statements were made with the knowledge that willful false
statements and the like so made are punishable by fine or imprisonment, or both, under 18 U.S.C. 1001.

Executed on ______ / _____ / __________ at _____________________________________ By _______________________________________
Date
City and State
Signature

_______________________________________________
Type or Print Name

______________________________________________
State License Number

PRA Act Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be
subject to a penalty for failure to comply with an information collection subject to the requirements of the
Paperwork Reduction Act of 1995, unless the information collection has a currently valid OMB Control
Number. The OMB Control Number for this information collection is 0651-0012. Public burden for this form
is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the information
collection. Send comments regarding this burden estimate or any other aspect of this information collection,
including suggestions for reducing this burden to the Chief Administrative Officer, United States Patent and
Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email [email protected].
Privacy Act Statement
The United States Patent and Trademark Office (USPTO) collects this information under authority of 5 CFR
339.205. The information in this system of records is used to manage biographical information, personal and
professional qualifications, character and fitness report, investigations of an applicant’s suitability or eligibility
for registration to practice before the USPTO, undertakings of former patent examiners, current address, and
status information. The information you provide is protected from disclosure to third parties in accordance
with the Privacy Act.
However, routine uses of this information may include disclosure to the following: Routine uses will include
publishing and disseminating a public roster including an address of record, law firm or company affiliation,
telephone number, and registration number of the active registered individuals on the USPTO Web site, to law
enforcement and investigation in the event that the system of records indicates a violation or potential
violation of law; to a Federal, state, local, or international agency, in response to its request; to an agency,
organization, or individual for the purpose of performing audit or oversight operations as authorized by law to
contractors and their agents, grantees, experts, consultants, and others performing or working on a contract,
service, grant, cooperative agreement, or other work assignment for the U.S. Patent and Trademark Office,
when necessary to accomplish an agency function related to this system of records; to the Department of
Justice for Freedom of Information Act (FOIA) assistance; to members of congress working on behalf of an
individual; to the Office of Personnel Management (OPM) for personnel research purposes; to National
Archives and Records Administration for inspection of records. Failure to provide any part of the requested
information may result in an inability to process requests for access and information. The applicable Privacy
Act System of Records Notice for this information is COMMERCE/PAT–TM–1 Attorneys and Agents
Registered to Practice Before the Office available at Federal Register /Vol. 78, No. 53 /Tuesday, March 19,
2013 /Notices
https://www.federalregister.gov/documents/2013/03/19/2013-06254/privacy-act-of-1974-system-of-records