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CONSUMER AFFAIRS DEPARTMENT OF CEMETERY AND FUNERAL BUREAU (California)

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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
DEPARTMENT OF
CONSUMER AFFAIRS
Request for Examination Accommodations
for Examinees with Disabilities
Administered by the
Department
of Consumer Affairs
Cemetery
and Funeral
Bureau
GUIDELINES AND FORMS
Page
1 of 7
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
DISABILITY ACCOMMODATION
REQUEST FOR EXAMINATION
This questionnaire should be submitted by the final published application deadline. Requests
must be supported by documentation certifying the disability from a qualified professional
appropriate for evaluating the disability. Granting of a request for examination
accommodations will be deferred until the necessary documentation is submitted. Mail
your completed questionnaire and documentation to: DCA, Cemetery and Funeral Bureau, 1625
North Market Boulevard, Suite S-208, Sacramento, California 95834
PLEASE TYPE OR PRINT
1. I am applying to take the examination.
2. Name (last, first, middle initial):
3. Address:
Street Address
City, State Zip Code
4. SSN:
5. Date of Birth:
6. What accommodation(s) are you requesting (please be specific)? Accommodation(s) must be
appropriate to the disability.
Page 2of 7
7. Nature of Disability:
Chronic Health Problem Physical Disability
Hearing Disability Visual Disability
Learning Disability Other
8. In order to document your need for accommodation as completely as possible, please attach, in
addition to professional documentation, a personal statement describing your disability and
how it impairs your ability to accurately exhibit knowledge and skill on the examination.
9. Certification/Authorization:
I certify that the above information is true and accurate. If test accommodations granted to
me include a deviation from the standard testing time schedule, I agree that, from the time I
begin the examination until I have completed it, I will not communicate in any way, to the
extent possible, with any other individuals taking the examination and I will not communicate
in any way with any such individuals about the content of the examination.
Signature Date:
If clarification or further information regarding the documentation provided is needed, I
authorize the state licensing authority to contact the professional(s) who diagnosed the
disability and/or those entities which have granted me test accommodations. I authorize such
professional(s) and entities to communicate with the state licensing authority in this regard to
provide the state licensing authority with such clarification and/or further information.
Signature Date:
Page 3of 7
_____________________________________
_____________________________________
_____________________________________
_____________________________________
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
PROFESSIONAL VERIFICATION OF
REQUEST FOR ACCOMMODATION
The purpose of this form is to request your professional opinion concerning the disability and the
accommodation requested. Please answer the two questions below and sign the certification. The
opinion you provide will be used in evaluating this request.
The information contained on this form will be treated as a confidential medical record except that
examination proctors and providers may be informed regarding necessary modifications to examination
procedures, and first aid and safety personnel may be informed, when appropriate, if the disability might
require emergency treatment.
PLEASE TYPE OR PRINT
NAME OF APPLICANT:
1. Please provide an evaluation and findings and describe the individual’s functional limitations
(attach additional sheets if needed).
2. Please provide specific recommendation(s) for examination accommodations, including a detailed
explanation of why the accommodations are needed.
I certify under penalty of perjury under the laws of the State of California that I have the necessary
specialized training to make the above diagnosis, that I personally examined the applicant named above,
and that the diagnosis and assessment of accommodation request is my professional judgment. I
understand that the Cemetery and Funeral Bureau may contact me (with the applicant’s permission) to
obtain further information if necessary, and that the Bureau may obtain an independent assessment by a
second professional.
Signature
Typed or Printed Name of Professional
Title
Date
________________________________
Name of Institution or Practice
_________________________________
Street Address
_________________________________
City, State, Zip Code
_________________________________
Telephone Number (area code included)
Page 4of 7
How to Request Examination Accommodations
1. Read the guidelines carefully.
2. Complete the attached form titled, “Disability Accommodation Request
for Examination.” Please sign the form where indicated.
3. Obtain professional verification of your disability on the attached form
titled, “Professional Verification of Request for Accommodation.”
Note: If the request is limited to wheelchair space, or sitting in the front
of the room, professional verification is not required.
4. Attach a personal statement describing your disability, and how it impairs
your ability to accurately exhibit your knowledge and skill on the examination.
Requests for examination accommodations must be received by the final
published application deadline.
Page 5of 7
Guidelines for Examinees with Disabilities
Requesting
Examination
Accommodations
The Department of Consumer Affairs (DCA) provides reasonable and appropriate
accommodations for examinees with documented disabilities at no additional cost.
Examination accommodations are adjustments to the testing activity for an individual with a
disability in order to ease the effect of the disability on the examination process. Reasonable
accommodations vary according to the type and degree of the disability. Accommodations will
be made on an individual basis, and will depend on the nature and extent of the disability,
documentation provided, and the requirements of the examination.
Documentation
Applicants requesting reasonable accommodations because of disabilities must provide
appropriate documentation of the disability and specify the extent to which the standard
examination procedures need to be modified.
The following documentation should be submitted to support a request for accommodations:
1. A completed Disability Accommodation Request for Examination, see attached form.
2. A completed Professional Verification of Request for Accommodation, see attached form.
This form is to be completed by a qualified professional to evaluate the disability and describe
the applicant’s condition and its severity. The form should include:
a) An evaluation and specific findings (relevant history, tests administered, test results
and interpretation of those test results)
b) A description of the individual’s functional limitations due to the stated disabilities
c) Specific recommendations for examination accommodations including an explanation
of why the accommodations are needed
d) Name, address, telephone number and qualifications of each professional expert who
provides documentation.
The DCA reserves the right to request further verification, if necessary, of the professional’s
credentials and expertise relevant to the diagnosis being made. The DCA also reserves the right
to require further evaluation of the applicant by a professional of its choice at its expense.
Time for Submitting Documentation
An applicant must notify the DCA, Cemetery and Funeral Bureau in writing no later than the
final published application deadline that he or she has a disability and is requesting examination
accommodations. To accelerate the review process, applicants are urged to submit their request
and supporting documentation as early in the application process as possible.
Page 6of 7
Examination Accommodations
Examination accommodations include but are not limited to the following:
Assistance in completing the answer sheet
Audio tape
Extended examination time
Extra or extended breaks (without extended testing time for the examination
Individual testing room )for those whose disability necessitates separation from all other
examinees)
Large print examination
Printed copy of verbal instructions read by the proctor
Reader
Other accommodations will be considered upon request.
Application for Subsequent Test Accommodations
If there is additional or different accommodations being requested, documentation f or the new
request must be submitted according to appropriate deadlines.
Page 7of 7
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information
The Cemetery and Funeral Bureau of the Department of Consumer Affairs collects the
personal information requested on this form as authorized by Business and Professions
Code Sections 30, 144, 7617.1, 7618, 7619, 7620, 7628, 7642, 7643, 7661, 7662, 7665,
7667, 9650, 9650.2, 9650.3, 9700, 9701, 9702.1, 9704, 9715, 9715.1, 9716, 9723,
9723.1, 9741, 9745, 9746, 9781, 9787.3 and the Information Practices Act. The
Cemetery and Funeral Bureau uses this information principally to identify and evaluate
applicants for licensure, issue and renew licenses, and enforce licensing standards set by
law and regulation.
Mandatory Submission
Submission of the requested information is mandatory unless otherwise noted on the
form. The Cemetery and Funeral Bureau cannot consider your application for licensure or
renewal unless you provide all of the requested information.
Access to Personal Information
You may review the records maintained by the Cemetery and Funeral Bureau that
contain your personal information, as permitted by the Information Practices Act. See
below for contact information.
Possible Disclosure of Personal Information
We make every effort to protect the personal information you provide us. The information
you provide, however, may be disclosed in the following circumstances:
In response to a Public Records Act request (Government Code Section 6250 and
following), as allowed by the Information Practices Act (Civil Code Section 1798 and
following);
To another government agency as required by State or Federal law; or,
In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information
For questions about this notice or access to your records, you may contact the Custodian
of Records, Cemetery and Funeral Bureau at 1625 North Market Boulevard, Suite S-208,
Sacramento, CA 95834, by phone at (916) 574-7870, or by e-mail at
emailcfb@dca.ca.gov. For questions about the Department’s Privacy Policy, you may
contact the Department of Consumer Affairs at 1625 North Market Boulevard,
Sacramento, CA 95834, by phone at (800) 952-5210, or by e-mail at dca@dca.ca.gov.
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CONSUMER AFFAIRS DEPARTMENT OF CEMETERY AND FUNERAL BUREAU (California)

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Completed 8 June 2021

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