GED Test Accom App Learning Disabilities

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					                                                    Checklist for Completing
                           Learning and Other Cognitive Disorders
                              Testing Accommodations Request Form(s)

This checklist can be used to assist you, the GED testing candidate (or an advocate acting on behalf of the candidate), and the Chief Examiner
at your local GED Testing Center with instructions on how to properly complete the GED Testing Accommodations Request form.
You do not need to submit this form with your request for accommodations.

Candidate Last Name: _________________________________ Candidate First Name: ____________________________________
Candidate Social Security or Social Insurance Number: ________-_____-________
Be sure to ask the Chief Examiner at your local GED Testing Center any questions you may have about any part of the documentation/request
process that you do not understand.

       As of 09/01/05, The GED Testing Office no longer accepts forms L-15 or SA-001. Please obtain the appropriate disability form from your
        local GED Testing Center or online at http://www.emsc.nysed.gov/ged/mods.shtml. The approved forms are: 1) Learning and
        Cognitive Disabilities, 2) Attention-Deficit/Hyperactivity Disorder, 3) Emotional/Mental Health, and 4) Physical/Chronic Health Disability.

       Complete the GED candidate section (Section One) at the top of the request for accommodation form(s), providing complete
        and accurate information in all areas of this section.
     Be sure to sign the candidate signature line of the request for accommodation form(s). If you are under the age of 18, a parent or
      guardian must also sign.
     Be sure the professional diagnostician or advocate has completed all of the appropriate sections. Your advocate may assist
      you by providing information from your medical and/or educational records onto your request for accommodations form(s). The
      advocate can also sign on Section Three as long as the name of the professional diagnostician is listed.
     A letter from the specialist making the diagnosis is not required for learning and other cognitive disability accommodation
      requests, however, the candidate’s IQ and Achievement test scores must be provided. The IQ and Achievement test scores
      must be less than five years old from the date of the accommodations request.

     Return your completed request for accommodations form(s) and all supporting documentation to the GED Chief Examiner at
      the testing center where you will take your test.




    Provide the professional diagnostician, advocate or candidate with the appropriate accommodation request form, which can be
     downloaded from http://www.emsc.nysed.gov/ged/mods.shtml.
    To assist with the application process, provide the candidate and/or advocate with all relevant resources (e.g., information on how to
     complete the form, test schedules for your test center, brochures/pamphlets, etc.).
    The Chief Examiner must complete and sign Section Two before it is submitted to the GED Testing Office for review. The Chief
     Examiner must review the entire form to ensure all information is complete and all relevant supporting documentation is attached.
If the Application Request has not been completed by the candidate, advocate, and/or diagnostician:
           Return application to professional diagnostician, advocate or candidate for additional information/documentation.
                 Provide the professional diagnostician, advocate or candidate with specific written directions for properly
                 completing the forms, including:
                      Date returned: ___________________
                      Items needed to complete the forms:_____________________________________________________________
When the request has been completed, mail the entire application to the NYSED GED Administrator. Date sent: _______________
      8051




Last Name: _____________________________________________                        First Name: ___________________________________
Social Security or Social Insurance Number: _____-____-_________                Birth Date: ____/____/________      Age: ____________
Address: ________________________________________________
City: ___________________________             State: ______________             Zip/Postal Code: _______________________________

Phone Number: (       )      -

Release of Information: If you are under 18 years of age, your parent or guardians signature is also required.
I grant permission to school officials and my healthcare provider(s) to release my education-related records and/or my medical or psychological
records to the GED Testing Service and its designees in connection with my request for testing accommodations.




Chief Examiner Name: __________________________________                         3 Digit SED Center Code: ________________________
Center Name: _________________________________________                          10 Digit GEDTS Center ID# ______________________
Phone Number: (       )      -             Fax Number: (      )     -           Email Address:

I have reviewed this application and confirm that it is complete.

       _______________________________________________________________________________________




Please indicate your role:       Professional Diagnostician                 Advocate
Name of Professional Making Diagnosis (please print): _________________________________________________________________
Phone Number: (       )      -                                          Date of Assessment: ____/____/__________________________
Licensure or Certification: ______________________________              Expiration Date: ____/____/_____________________________
State/Province: ___________           Number:________________           Specialty:____________________________________________
Name of Advocate (please print): __________________________________________________________________________________
Relationship to Candidate (please print): __________________________________Phone Number: (             )     -
Professional Making Diagnosis or Advocate’s Signature: _____________________________________Date: _____________________
LD- page 1 of 5
         Date(s) of Assessment: ____/____/________




Please indicate your role:       Psychological Diagnostician               Advocate
Name of Psychologist (please print): ________________________________________________________________________________
Phone Number: (       )      -                                         Fax Number: (   )    -
Highest Degree and Area of Specialization: ___________________________________________________________________________
Licensure Number: ________________________             Expiration Date: ____/____/________ State/Province/Terr: __________________
State/Province: ___________          Number:________________           Specialty:____________________________________________
Name of Advocate (please print): __________________________________________________________________________________
Relationship to Candidate (please print): __________________________________Phone Number: (         )     -
Psychologist Making Diagnosis or Advocate’s Signature: _____________________________________Date: ______________________


LD – page 2 of 5
       Date(s) of Assessment: ____/____/________




LD – page 3 of 5
Specific Learning Disabilities (check all that apply)
               Reading Disability (identify: ______________________________________________________________________________)

               Mathematics Disability (identify: __________________________________________________________________________)

              Written Language Disability (identify: ______________________________________________________________________)

            Other Cognitive disabilities (list all that apply):
___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

    DSM IV Code(s):___________________                   _____________________                 _____________________




               Extended Time (please specify):          1 ½ times         2 times          Other:______________________________________
               Audiocassette (tone-indexed) (requires extended testing time, generally double time)
                        2 times          Other: ____________
                   The use of this accommodation requires practice. Candidates should have an opportunity to practice using an Official GED
                   Practice Test, Audiocassette Version prior to the scheduled testing date.
               Braille
               Scribe
               Calculator for Part II
               Talking Calculator for entire mathematics test.
               Private room
               Supervised Breaks (specify in minutes):
                  Uninterrupted testing time:________ minutes, break time:________ minutes
               Other________________________________________________________________________________________




________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

___________________________________________________________________________________________________________________
General Educational Development (GED) Testing Service will not discriminate against candidates for testing on the basis of any legally
protected characteristic, including, but not limited to, race, color, religion, sex, sexual orientation, pregnancy, marital status, physical or mental
disability, age, veteran status, and national origin.

LD – page 4 of 5
             Approved for:

                         Extended Time (please specify):        1 ½ times                2 times                     Other: ________

                         Audiocassette (tone indexed) (requires extended testing time, generally double time)

                                 2 times                  Other: ________
                            The use of this accommodation requires practice. Candidates should have an opportunity to practice using an

                            Official GED Practice Test, Audiocassette Version prior to the scheduled testing date.


                         Braille
                         Scribe
                         Calculator for Mathematics part II
                         Talking calculator for entire Mathematics Test
                         Private Room
                         Supervised Breaks (specify in minutes):
                            Uninterrupted testing time:________ minutes, breaks time:________ minutes
                         Other__________________________________ ____________________________________________________

             Returned for more information.                                                  Date Returned: ____/____/________

                   Reasons for returning request:
                   ____________________________________________________________________________________________________

                   ____________________________________________________________________________________________________

                   ____________________________________________________________________________________________________

             Request forwarded to GEDTS for review (explain reasons below)                   Date Forwarded: ____/____/________

                   Reasons for forwarding request to GEDTS for review:

                   ____________________________________________________________________________________________________

                   ____________________________________________________________________________________________________

                   ____________________________________________________________________________________________________


        _____________________________                                       _(518) 474-2801___               __________________

        GED Administrator's Signature                                       Telephone Number                 Date


LD – page 5 of 5

				
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