ABO-NCLE ADA Accommodation Form

ABO-NCLE ADA Accommodation Form
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com

Accomodations History

Indicate any previous accommodations you have received and the corresponding dates
Standardized Examination
Educational Institution

Nature of Disability

For each impairment, indicate the year of diagnosis in provided box
Language Impairments
Learning Impairments
Medical Impairments
Mental Health Impairments
Sensory Impairments
Requested Accomodations

Indicate the specifice accomodation(s) you are requesting; accomodations must be applicable to the disability. (Requests will not be processed if no accomodations are requested below.)

Additional Documentation

Unacceptable Forms of Documentation

Please do not submit the following documents. ABO & NCLE will not accept them.

• Handwritten letters from licensed professionals

• Handwritten patient records or notes from patient charts

• Diagnoses on prescription pads

• Self-evaluations found on the internet or in any print publication

• Research articles

• Original evaluation documents; please submit copies of the original documents

• Previous correspondence from ABO & NCLE. We maintain copies of all correspondence.

• Correspondence from educational institutions or testing agencies not directly addressed to the ABO & NCLE
Current evaluation report (from within the past three years) from the appropriate health care professional.

The document must be on official letterhead, and should include the professional’s credentials, signature, address, and telephone number. The report must indicate the candidate’s name, date of birth, and date of evaluation. The report should include information concerning the specific diagnostic procedures or tests administered, diagnostic methods used should be appropriate to the disability and in alignment with current professional protocol, the results of the diagnostic procedures and tests and a comprehensive interpretation of the results, the specific diagnosis codes of the disability, with an accompanying description of the candidate’s limitations due to the disability, a summary of the complete evaluation with recommendations for the specific accommodations and how they will reduce the impact of the identified functional limitation.
Upload current evaluation here*

Browse Files

Cancelof
Documentation of any previous accommodations provided by educational institutions or other testing agencies.
If no prior accommodations were provided, the licensed professional should include a detailed explanation as to why no accommodations were given in the past and why accommodations are needed now.*

Browse Files

Cancelof

Authorization

I, the undersigned, certify that the information I have provided is correct. I give permission to the Department of Testing Services to contact the licensed professional who diagnosed my disability and the educational institution that granted me previous testing accommodations for additional information for clarification as needed. I authorize such professionals and educational institutions to provide ABO-NCLE with such clarification and further information as needed.
Signature*

Clear
Should be Empty: