Application for ADA Assessment Accommodations
Purpose of this Form
This form must be completed by individuals requesting special accommodations for assessments under
the Americans with Disabilities Act (ADA). Before
completing this form, please review the supporting information on our website:
https://www.theabr.org/exam-dates-and-information/exam-accommodations
.
Forms must be submitted by the published deadline (see timelines on the above webpage) and include supporting documentation as described.
You must submit a new request for each assessment you wish to receive accommodations.
Contact Information
First Name
*
Last Name
*
ABR ID
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
Phone Number
*
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ABR Discipline:
*
Diagnostic Radiology
Interventional Radiology
Radiation Oncology
Medical Physics
Subspecialty
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DR Assessment for which you are requesting accommodations:
*
Core Exam
Certifying Exam
Continuing Certification Exam
OLA
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IR/DR Assessment for which you are requesting accommodations:
*
Core Exam
Certifying Exam - Computer Based
Certifying Exam - Oral Component
Continuing Certification Exam
OLA
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RO Assessment for which you are requesting accommodations?
*
Initial Qualifying (Physics, Biology, and/or Clinical)
Oral Certifying Exam
Continuing Certification Exam
OLA
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MP Assessment for which you are requesting accommodations:
Initial Qualifying (Part 1 or Part 2)
Oral Certifying Exam
Continuing Certification Exam
OLA
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Subspecialty Assessment for which you are requesting accommodations:
*
Neuroradiology
Nuclear Radiology
Pain Medicine
Pediatric Radiology
Continuing Certification Exam
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What type of accommodation are you requesting?
*
ADA
Military Related
Have you previously requested accommodations for an ABR assessment?
*
Yes
No
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ADA Special Provision:
Hearing
Learning
Physical
Chronic Health Problem
Temporary injury
Visual
Other
What accommodation are you requesting? (i.e., additional time, special equipment, etc.) You must submit supporting documentation for your request to be reviewed.
*
Please note:
For computer-based exam requests, the maximum amount of extra testing time you may request is time and a half.
For an OLA ADA Request, you can only request additional time (time and a half).
Please attach documentation supporting your request for accommodations. You must submit supporting documentation for any request. If you do not submit supporting documentation, your request may be denied.
*
Select File
Cancel
of
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Military Related Request:
What accommodation are you requesting? (i.e., additional time, special equipment, etc.)
*
Please attach documentation supporting your request for accommodations. You must submit supporting documentation for any request. If you do not submit supporting documentation, your request may be denied.
*
Select File
Cancel
of
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By clicking "Submit", I acknowledge and agree that I bind and legally obligate myself to the same extent as I would by signing my name on a printed version of this form.
Signed: (please type your full name)
*
For questions or concerns please contact:
abradministration@theabr.org
.
Please allow up to two weeks for processing of your request. If you do not hear from us within that time, please email
abradministration@theabr.org
or call (520) 790-2900.
Submit
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