Fillable Certreqnew Test Accommodations Request Form: New Request

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Certreqnew Test Accommodations Request Form: New Request

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The Certreqnew Test Accommodations Request Form: New Request form is 4 pages long and contains:

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  • 27 check-boxes
  • 31 other fields

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Test Accommodation Request Form
New Request
Please type or print.
Accommodations are requested for the following examination:
Examination: _______________________________________________ Year: __________________
1. Your Name: _____________________________________________________________________________
Last First Middle Initial
2. ABP ID #: _________________________ (if known)
3. Contact Information: _________________________________________________________________
Daytime Telephone Mobile Telephone
__________________________________________________________________
Email Address
4. Nature of Disability:
Visual Disability Physical Disability
Hearing Disability Psychiatric/Mood Disorder
Learning Disability Other: ___________________________________
Attention Deficit/Hyperactivity Disorder
5. Optional: To support your request, you may attach, in addition to professional documentation, a personal statement
describing your disability and its impact on your daily life and educational functioning. If relevant, also describe any
current workplace accommodations.
6. How long ago was your disability first professionally diagnosed?
less than 1 year 1–2 years 2–4 years 5 or more years
Please carefully review the ABP’s Policies and Procedures for Applicants with Disabilities to ensure that you provide the
required documentation from a qualified professional. Submission of incomplete information will delay the processing
of your request.
Send your completed form with supporting documentation by the final published deadline to: American Board of Pediatrics, 111
Silver Cedar Court, Chapel Hill, NC 27514, or by email to:
General Pediatrics Certification: gpcert@abpeds.org; Maintenance of Certification: moc@abpeds.org; Subspecialties:
sscert@abpeds.org; Subspecialty In-Training Examination: site@abpeds.org.
Applicants will select a computer testing center after a decision has been made on the test accommodation request.
Website: www.abp.org
General Email: abpeds@abpeds.org (or see www.abp.org for direct email addresses for each examination)
7. What accommodation(s) are you requesting? Accommodation(s) must be appropriate to your disability. (Check all that
apply)
Certifying, Maintenance of Certification and Subspecialty In-Training Exams:
Assistance with marking answers
Extended testing time
Amount requested as supported by your documentation:_________________________
(i.e., additional 30 minutes per test session; time and one half, or double time)
Screen magnification
Zoom text
Reader
Individual testing room (for those whose disability necessitates separation from all other examinees)
Special physical accommodations at the site
(special lighting, chair, etc.) _____________________________________________
Extended Breaks (explain; please be specific)
____________________________________________________________________
Other____________________________________________________________________
MOCA-Peds:
Extended testing time
Amount requested as supported by your documentation:_________________________
(i.e., time and one half, or double time to read and answer each test item)
Note: Those who need enlarged font or text for MOCA-Peds may use features on the computer browser to
accomplish this; a request for this accommodation does not need to be submitted to the ABP.
8. Have you received classroom or test accommodation(s) in the past?: Yes No
If yes, please complete Sections A-C below.
A. Standardized Examinations (Check all that apply)
Attach documentation showing the accommodations granted when the examination was administered.
Medical College Admission Test (MCAT) Month/Year: _________________________
Accommodation(s) received: ______________________________________________
United States Medical Licensing Exam (USMLE) Month/Year: ____________________
Accommodation(s) received: ______________________________________________
Other: _______________________________________Month/Year: ___________________
Accommodation(s) received: ______________________________________________
B. Medical School/Residency Yes No
If yes, provide a statement from your medical school and/or residency training program explaining the type of
accommodations made and date approved.
C. College Yes No
If yes, accommodation(s) received: ______________________________________________
Certification of Prior Test Accommodations
10. Authorization:
I certify that the above information is true and accurate. If testing 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 ABP to contact the
professional(s) who diagnosed the disability and/or those entities which have provided me test accommodations. I
authorize such professional(s) and entities to communicate with the ABP in this regard to provide ABP with such clarification
and/or further information.
Signature ___________________________________________ Date _______________________
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Certification of Prior Test Accommodations
To be completed by a medical school official responsible for student disability services.
Please type or print.
Applicant Name: ________________________________________________________________________
I, ___________________________________, hold the position of ________________________________. I certify
Name Title
that _______________________________________ has officially approved and provided the following test accommodations
Name of Institution
for the above applicant beginning on ____________________________.
Date (Month/Year)
Accommodation(s) provided:
Reason for provision of accommodation(s):
Signature __________________________________________ Date _____________________________
Telephone Number __________________________________
Effective 02/01/2006
(revised 2011, 2012, 2016)
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Certreqnew Test Accommodations Request Form: New Request

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Completed 18 February 2022

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