Application For Testing Accommodations - Form E

FORM E TESTING ACCOMMODATIONS MENTAL DISABILITY VERIFICATION To be completed by a physician/licensed professional (Please print or type) Name of applicant requesting testing accommodations __________________________________ Name of physician/licensed professional _____________________________________________ Address ______________________________________________________________________ Street Address or P.O. Box Number _____________________________________________________________________________ City, State and Zip Code Telephone Number _______________________________ Title and Specialty ______________________________________________________________ Describe briefly the applicants current self-reported symptoms of mental or psychological disabilities: Does the condition substantially limit the performance of a major life activity? _____ If YES, explain: Is there evidence of a comorbid personality disorder? _______ If YES, please describe: -1- <<<<<<<<<********>>>>>>>>>>>>> 2Is this person being treated for the condition? _______ If YES, describe treatment? What remediation techniques have been attempted? Have they worked? How does this condition affect the applicants ability to complete the examination under standard conditions? Is there any objective evidence that the requested accommodations have facilitated the applicants test performance in the past? _______ If your answer is in the affirmative, please fully explain: Based on the information above, the petitioners condition and your diagnosis, what testing accommodations would you recommend? Explain how the recommended testing accommodations relate to the functional limitations associated with the disability and the basis for that determination. Give specific examples: -2- Are there any corrective measures that would improve the applicants ability to take the <<<<<<<<<********>>>>>>>>>>>>> 3examination under standard testing conditions? If so, what are those measures? Mental or psychological disabilities will be considered temporary and therefore the applicant will need to be re-evaluated if testing accommodations are required for subsequent examinations. Attach a psychological report that includes the following information: * Full mental status * Psychological history * Development milestones * Educational history * Evaluation of tests administered * Diagnostic formulation * Prognosis Physician/Licensed Professionals Signature I declare under penalty of perjury under the laws of the State of Iowa that the above information is true and correct. ____________________________________ __________________ _______________ Signature of Physician/Licensed Professional License/Certification No. Date The Board of Law Examiners reserves the right to make a final judgment concerning testing accommodations and may, in its discretion, seek an independent evaluation from a medical specialist, psychologist, psychiatrist or other qualified specialist. Each case will be evaluated on its facts. 2000 -3-