Exam Accommodation Request Form

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Pearson VUE REASONABLE ADJUSTMENT

REQUEST FORM – Brief version*

Please complete sections #1 and 2 of this request form and attach supporting documentation as

detailed in section #3 of this form to complete your request.

SECTION 1: CANDIDATE’S IDENTIFYING INFORMATION

FULL NAME:

CERTIPORT USERNAME or CERTIPORT ID:

DATE OF BIRTH: / / AGE:

MONTH DAY YEAR

ADDRESS:

CITY/STATE/COUNTRY:

ZIP/POSTAL CODE PHONE NUMBER:

CANDIDATE EMAIL:

TEACHERS and PARENTS: If you wish to receive determination notifications, include your email here.

EMAIL #2:

If you are under 18, a parent or guardian must also sign.

(If you are over 18, please skip to Section #2.)

PARENT/GUARDIAN’S NAME

(IF CANDIDATE IS UNDER 18):

PARENT/GUARDIAN’S SIGNATURE

(IF CANDIDATE IS UNDER 18):

*Note: This form is to be used by candidates requesting reasonable adjustments for “low-stakes” testing. Low-stakes

testing does not include testing for licensure, professional entrance exams, or credentialing. In the future, if you choose to

take one of these “high-stakes” exams, you may need to provide additional documentation of your disability and need for

adjustments.

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SECTION 2: REQUESTED ADJUSTMENTS

Please indicate the name(s) of the exam(s) for which you are requesting reasonable

adjustments (please be specific):

 Exam name(s): ____________

______________________________________________________

Please indicate what reasonable adjustments you are requesting, and provide a rationale

for each:



 Extended Time: Standard time + 100%

 Other (specify)

Rationale for each requested adjustment:

WHAT IS YOUR DISABILITY? (Check all that apply)

 Learning or other Cognitive Disorders (i.e., dyslexia)

 Attention-Deficit/Hyperactivity Disorder (ADD/ADHD)

 Psychological and Psychiatric Disorder (i.e., depression, bipolar disorder)

 Physical Disorders and Chronic Health Conditions (i.e., a vision disorder, mobility

impairment)

Notes:

1. We reserve the right to request evidence as to the qualifications of the professional or doctor whose

documentation is submitted.

2. If Pearson VUE has additional questions about the candidate’s access needs, candidate agrees to

participate in an interactive process to determine how his/her needs can be met.

This request form and

supporting documentation may be faxed to 801-492-4160 or mailed

to Certiport Accommodations, 5601 Green Valley Drive,

Bloomington, MN 55437.

Emailed requests cannot be accepted.

QUESTIONS? EMAIL US: ACCOMMODATIONSCERTIPORT@PEARSON.COM

Effective 2/13/20

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SECTION 3: GUIDELINES FOR REASONABLE ADJUSTMENTS—BRIEF VERSION

INTRODUCTION

Pearson VUE is committed to ensuring access to testing programs for all individuals with disabilities.

Pearson VUE provides reasonable adjustments to individuals with documented disabilities who

demonstrate a need for such. For example, applicants with documented medical, sensory, motor,

psychiatric or learning conditions may request extra testing time or a separate testing room. It is

essential that the documentation provide a clear explanation of the current functional limitation and

a rationale for the requested adjustments.

DETAILED DOCUMENTATION GUIDELINES

All candidates who are requesting reasonable adjustments must provide current documentation

stating their disability and rationale for the requested adjustments.

How old is your supporting documentation?

DISABILITY CATEGORY ................................................ MAXIMUM AGE OF DOCUMENTATION

Learning and other Cognitive Disorders (dyslexia)……………………………............. 5 Years

Attention-Deficit/Hyperactivity Disorder (ADD/ADHD)……… .......................... 5 Years

Psychological and Psychiatric Disorders..................................................... 1 Year

Physical Disorders and Chronic Health Conditions....................................... 1 Year

One or more of the following documents should be submitted with the

applicant’s request form:

 Educational or psychological report

 Current or recent school-based special education plan

 Detailed letter from a qualified professional that describes the disabling condition,

functional limitations, and rationale for the requested adjustments

Any documentation that is submitted must:

 Include a clear diagnosis

 Be printed on the evaluator’s or school’s official letterhead

 Be signed and dated by the evaluator, doctor, or school official

 Provide information on current functional limitations that are likely to affect the

candidate’s ability to take the exam under standard conditions



Provide a specific rationale for each requested adjustment

Effective 2/13/20