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By submitting this form to the PDE, the LEA provides the following assurances:
o This one-time exception applies only to the above referenced student.
o This accommodation is documented in the student’s IEP/504 Plan.
o The IEP/504 team has met and has considered all standard (allowable) accommodations prior to proposing this
unique accommodation.
o Parent(s)/guardian(s) and student were provided an opportunity to participate in the decision-making process
for this accommodation.
o The proposed accommodation is used for routine class instruction and assessment.
o Test administrator must monitor all test sessions.
o This exception is based on the student’s inability to produce a written response by any other means.
o The use of this accommodation will not change the construct of what is being measured on the test.
If a device is being used:
o NO internet, grammar, punctuation, spell-check, dictionary, thesaurus, content-specific word prediction lists,
apps or formulas may be turned on or used for the student responses.
o The camera, email, text-to-speech, references, formulas, other calculating functions, iCloud, Google Drive,
synchronization and connection to other devices, internet functions, and all help functions must be disabled on
the device.
o The test administrator deletes all files from the device that will give student access to any assistance in
answering the PSSA and/or Keystone test items. This includes all formulas, problem solving steps, algebraic
principles, examples, models, and any other material, files, links, or other sites that may assist the student in
choosing the correct answer.
o The text-to-speech feature must be disabled.
o The test administrator may not “correct” the electronic response due to an incorrect term or word choice by the
student or software program.
o The test administrator may not interfere with the student’s response in any way.
o When the student is finished with the exam and exits the managed guest session, the session is wiped from the
device.
o Therefore, NO printed or electronic copy/version of the PSSA and/or Keystone test documents may be saved,
forwarded, emailed, or otherwise kept or distributed by or to any person whatsoever.
o All electronic or printed copies of student responses must be completely deleted and/or destroyed by the
assessment coordinator.
o At completion of each test, the entire PSSA and/or Keystone exam must be completely removed from the
computer’s hardware and/or other data storage device by the assessment coordinator.
o Accurate documentation of this accommodation must be kept in the student’s file.
District Assessment Coordinator/School Assessment Coordinator and Special Education Coordinator must sign the
Unique Accommodation Confidentiality Agreement located in the Accommodations Guidelines. The signed agreement
must be kept on file at the LEA with this form.
District Test Coordinator: ____________________________________________________________________________
School Assessment Coordinator: _______________________________________________________________________
Special Education Coordinator: ________________________________________________________________________