ATI TEAS Exam at Sac State Testing Center

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Student ID (if applicable)*

Primary disability for which you are requesting accommodations*

Date of Diagnosis*

Have you already registered for the TEAS exam?*

YesNo

If applicable, please provide the date on which you registered for the TEAS exam. (Please be aware that accommodation requests may require up to 30 days for processing.)

Accommodation(s) Requested for TEAS Exam*

Attach a letter from an object physician or healthcare professional*

Attach a letter from an objective physician or healthcare professional qualified to diagnose the disability or medical condition and render an opinion as to the need for accommodation. An “objective” professional is one who is not the requestor or related to the requestor. The letter must be dated within 2 years of the anticipated date of your exam. If you are a high school student, or post-secondary student who is within 2 years of high school graduation, an Individual Educational Plan (IEP) may be used in lieu of the letter provided the IEP is actively in place. The letter or IEP MUST include the following: The specific disability/diagnosis. Mental/emotional disabilities must be accompanied by a numerical DSM-IV classification code. A brief explanation of how this condition limits the candidate’s ability to take the exam under standard conditions. If this is not a permanent disability or diagnosis, include date first diagnosed, approximate duration, and method used to make the diagnosis. Specific accommodations required. These accommodations should be adequate without creating an unfair advantage. Please note that candidates who require extra time to complete the exam will be given 1 1/2 times the standard allotted time. If more time is needed, the letter or IEP must specifically state how much time is needed and why that amount of time is required. Generally, this information is contained in the triennial psychoeducational evaluation section of the IEP.

Verification Statement to be Signed by Applicant*

I attest to the fact that the information recorded on this application is true, and if this application is not sufficient, I agree to provide Sac State Testing Center with any additional information or documentation requested in order to evaluate my request for accommodations. I also give permission to release to Sac State Testing Center a copy of any pertinent information required to establish the need for the accommodation(s) requested herein. If I am requesting the use of an assistive device, I am familiar with its use. I understand that all information that is necessary to process this application must be available to Sac State Testing Center sufficiently in advance of the test administration date to provide time to evaluate and process my request for accommodations. I also understand that processing may take approximately four to six weeks from the time the application is complete. If additional documentation must be submitted, it may be another two to four weeks from the time the new documentation is received until the review is complete. I acknowledge that Sac State Testing Center reserves the right to make final determination as to whether any requested accommodation is warranted and appropriate.