Alternative Testing Arrangements Request Form

A red asterisk * indicates a required field.

Alternative testing arrangements may only be applied to unscheduled test registrations.

Prior to submitting this form: • Register for the test(s) for which you are requesting accommodations. • Do not schedule your appointment. If you did schedule a test date, please cancel your appointment before completing and submitting this form.

First Name:*

Middle Initial:

Last Name:*

Last 4 digits of Social Security Number:*

Email:* (As listed in your registration account)

Confirm Email:*

Mailing Address:*

Address Line Two:

City:*

State/Province/Region:*

Zip/Postal Code:*

Country:*

Daytime Phone:*

Evening Phone:

Test date: You will schedule your appointment once your request for alternative arrangements has been resolved.

Indicate the test center that you are requesting: * Current Characters (Max 500): 0

Identify the disability for which you are requesting alternative testing arrangements:* Current Characters (Max 500): 0

List the specific alternative testing arrangement(s) that you are requesting (please note: only the requests listed will be considered):* Current Characters (Max 1000): 0

If you plan to bring a medical device into the testing room, please provide the make and model of any device(s) you intend to bring: Current Characters (Max 500): 0

Documentation (check one of the following)*:

I am requesting one of the alternative testing arrangements listed below because of a disability. Medical documentation is not required for the following accommodations: • Wheelchair-accessible facilities. • Frequent breaks (e.g., for those with hypoglycemia or diabetes). I am requesting alternative testing arrangements other than those listed above. Therefore, I have enclosed documentation, if required, as indicated on the current program website. I have been approved for alternative testing arrangements for this testing program in the past. The accommodations I am requesting and the condition of my disability have not changed. Therefore, the documentation I have previously submitted may be used.

Previous Alternative Testing Arrangements (check one of the following)*:

I have not previously been granted alternative testing arrangements. For a previous test session, I was granted the same alternative testing arrangements as I am currently requesting. For a previous test session, I was granted different alternative testing arrangements from those that I am currently requesting.

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I have completed the registration process for the THEA Internet-Based Test and agree to abide by the conditions set forth on the THEA IBT Web site, including the Rules of Test Participation for the THEA IBT, and I certify that I am the person whose name and address appear on this form. I am submitting, together with this completed Alternative Testing Arrangements Request Form for THEA IBT, any required documentation as noted. I understand and agree that the alternative testing arrangements I have requested herein will be given due consideration. If, and to the extent that, any such request is granted, I understand that I will be taking the test under alternative conditions. Agree*

Please check the box below.

Please note, this form must be submitted with each registration.