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ADA ACCOMMODATION REQUEST Application

Please follow these instructions to submit your ADA request and documentation:
  • If you have a disability for which you wish to request an accommodation, please complete this application, along with uploading the required documentation supporting your diagnosed disability (*see below) and need for accommodations.
    • English as a second language is not an ADA-eligible disability for accommodations during competency testing. 
  • Accommodations will NOT be provided at the examination site unless an accommodation is granted prior to testing through this application process.
  • Any specialized equipment required must be provided by the candidate.
  • It is your responsibility to notify the testing program of the needed alternative arrangements.
  • An ADA request submitted without the required, appropriate documentation will not be reviewed until the required documentation is received.  
*REQUIRED DOCUMENTATION FOR ADA ACCOMMODATION REQUESTS:
An applicant requesting special testing accommodation must provide the following to D&SDT-Headmaster:
  • Documentation from the Health Care Provider or Learning Specialist who rendered a diagnosis.
    • Documentation including recent (within the last four years, unless the disability is documented by the professional as stable and permanent) reports, test results, evaluations, and assessments of the candidate’s need for accommodations due to a disability (physical or mental impairment) that substantially limits one or more major life activities. Major life activities include walking, seeing, hearing, speaking, breathing, learning, thinking, working, caring for one’s self, and performing manual tasks. Mental impairment includes any mental or psychological disorder, such as organic brain syndrome, emotional or mental illness, and specific learning disabilities, which are protected under the Americans with Disabilities Act (ADA).  Documentation by a qualified professional with expertise in the areas of the diagnosed disability that supports the request for accommodations, including results of appropriate diagnostic testing, must be submitted.
    • A copy of verification on the letterhead stationery of the Health Care Provider or Learning Specialist must be uploaded with this application and must include the following:
    • Specific description of the disability and limitations related to testing.
    • A history of the disability and any past accommodations(s) granted to the candidate, as well as a description of its impact on the individual’s functioning.
    • Specific recommended accommodation(s).
    • Name, title, and telephone number of the Health Care Provider or Learning Specialist.
    • Signature of the Health Care Provider or Learning Specialist. 
IMPORTANT NOTES:
In order to grant testing accommodations, D&SDT-Headmaster must share information concerning your request with the RN Test Observer/Certified Evaluator, who will observe your performance on the manual skill portion, and the Knowledge Test Proctor who will administer the knowledge portion of the examination. The information requested below and any documentation regarding your disability is considered strictly confidential and will be shared only with the RN Test Observer/Certified Evaluator and their Knowledge Test Proctor and Actor, and appropriate State Agencies.

All requests will be considered on a case-by-case basis. It will be necessary for testing staff to speak and correspond with you regarding specific arrangements. Therefore, it is IMPORTANT that you provide a current email, address, and daytime telephone number and keep D&SDT-Headmaster informed if any of these change. 

Please allow at least 10 business days for your request to be reviewed.  This time frame may be longer if D&SDT-Headmaster or the State Agency has to reach out for more information, etc. 
  • D&SDT-Headmaster will review and approve or deny any accommodations and inform you via email of any approved or denied accommodations for testing.
  • An ADA request submitted without the required, appropriate documentation will not be reviewed until the required documentation is received.
 You MUST notify D&SDT-Headmaster (or in some instances, notify the testing staff) if you are unable to take the examination on the date for which you are scheduled.
 
D&SDT-Headmaster Approval Process:
The request for accommodation is reviewed by D&SDT-Headmaster.  D&SDT-Headmaster staff members shall critically review the documentation to ensure that the: 
  • Necessary information and documentation are complete and have been provided.
  • Documentation supports the diagnosis of an ADA-eligible disability.
  • Documentation supports the need for the requested accommodation.
  • Accommodation requested is reasonable and can be provided by D&SDT-Headmaster without: 
    • Creating an undue financial or administrative burden;
    • Posing a direct threat to others; or
    • Fundamentally altering the purpose of the examination, which is intended to verify your training, competency, and hands-on skill in the mandatory competency subject areas identified by law, including 42 CFR §§ 483.150 to 483.160.
During the course of the review, D&SDT-Headmaster staff may communicate with the applicant, program, or professional making the diagnosis to clarify the request or suggest available alternatives if the accommodation is not feasible. The decision to recommend or not recommend the accommodation is conveyed to the applicant via email. If the request is denied, the applicant may submit additional information to support their request.
 
Denial and Appeal Process | Transfer of Information | Record of Request
If D&SDT-Headmaster staff does not have sufficient evidence to grant the accommodation, the applicant will be informed of the requirements. The applicant may appeal staff findings to D&SDT-Headmaster by submitting a written request for appeal within 10 days of the notification of insufficient evidence to grant the accommodation.  
 
If there is information in the accommodation request that indicates the applicant’s condition poses a risk to the health, safety, and welfare of patients or the public, the information in the accommodation request will be provided to the investigations department and an investigation may be conducted.
 
All requests for accommodation are maintained and filed in the applicant’s file and are not considered public records.

The information requested and documentation regarding your disability is considered strictly confidential and will be shared only with the parties listed on a need-to-know basis.

Your application is not complete until the required information is included, then select 'Send Application'.
Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)
Address
ACCOMMODATION REQUEST INFORMATION
REQUIRED DOCUMENTATION FOR ADA ACCOMMODATION REQUESTS
Affidavit
By submitting this application, you give permission to D&SDT-Headmaster staff, RN Test Observers/Certified Evaluators, Knowledge Test Proctors, Actors, and appropriate State Agencies to be informed of your accommodations requested. The information requested and documentation regarding your disability are considered strictly confidential and will be shared only with the parties listed above on a need-to-know basis. 

You certify that you have provided and understand the following:
  • An ADA request submitted without the required, appropriate documentation will not be reviewed until the required documentation is received.
  • You have uploaded the required documentation from the Health Care Provider or Learning Specialist supporting your request for accommodations and,
    • the necessary information and documentation are complete and have been provided.
    • your documentation supports the diagnosis of an ADA-eligible disability.
    • your documentation supports the need for the requested accommodation.
    • your accommodation requested is reasonable and can be provided by D&SDT-Headmaster (see D&SDT-Headmaster's Approval Process above).
  • Accommodations will NOT be provided at the examination site unless an accommodation is granted prior to testing through this application process.
  • Any specialized equipment required must be provided by the candidate.
  • It is your responsibility to notify the testing program of the needed alternative arrangements.
  • English as a second language is not an ADA-eligible disability for accommodations during competency testing.
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.