Fillable Commonwealth of Massachusetts Board of Bar Examiners - Form 3 - Attention Deficit/Hyperactivity Disorder Verification

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Commonwealth of Massachusetts Board of Bar Examiners - Form 3 - Attention Deficit/Hyperactivity Disorder Verification

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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FORM 3: ATTENTION DEFICIT/HYPERACTIVITY DISORDER
VERIFICATION
NOTICE TO QUALIFIED PROFESSIONAL:
The above-named person is requesting accommodations on the Massachusetts Bar
Examination. All such requests must be supported by a comprehensive written evaluation
report from the qualified professional who conducted an individualized assessment of the
applicant and is recommending accommodations on the bar examination on the basis of
AD/HD. The Board of Bar Examiners also requires the qualified professional to complete
this form. If any of the information requested in this form is fully addressed in the
comprehensive evaluation report, you may respond by citing the specific page and
paragraph where the answer can be found. Please attach a copy of the comprehensive
evaluation report and all records and test results on which you relied in making the
diagnosis and recommending accommodations for the Massachusetts Bar Examination.
We appreciate your assistance.
The Board of Bar Examiners may forward this information to one or more qualified
professionals for an independent review of the applicant’s request.
Print or type your responses to the items below. Return this completed form, the
comprehensive evaluation report, and relevant records and test results to the applicant for
submission to the Board.
NOTICE TO APPLICANT: This section of this form is to be completed by you. The
remainder of the form is to be completed by the qualified professional
who is
recommending accommodations on the Massachusetts Bar Examination for you on the
basis of AD/HD. Please read, complete, and sign below before submitting this form to
the qualified professional for completion of the remainder of this form.
Applicant’s full name:
Date(s) of evaluation/treatment:
Applicant’s date of birth:
I give permission to the qualified professional completing this form to release
the information requested on the form, and I request the release of any
additional information regarding my disability or accommodations previously
granted that may be requested by the Massachusetts Board of Bar Examiners
or consultant(s) of the Massachusetts Board of Bar Examiners.
Signature of applicant: ____________________ Date:______________________
MASSACHUSETTS BOARD OF BAR EXAMINERS
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signature
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Form 3-Page
2
Rev.09/19
I. EVALUATOR/TREATING PROFESSIONAL INFORMATION
Name of professional completing this form:
Address:
Telephone: _____________________________ Fax:
E-mail:
Occupation and specialty:
License number/Certification/State:
Describe your qualifications and experience to diagnose and/or verify the applicant’s condition
or impairment and to recommend accommodations.
II. DIAGNOSTIC INFORMATION CONCERNING APPLICANT
1. Provide the date the applicant was first diagnosed with AD/HD. ______________________
2. Did you make the initial diagnosis? Yes No
If no, provide the name of the professional who made the initial diagnosis and when it was
made, if known. Attach copies of any prior evaluation reports, test results, or other
available records related to the initial diagnosis that you reviewed.
3. When did you first meet with the applicant?
4. Provide the date of your last complete evaluation of the applicant. _____________________
Form 3-Page
3
Rev. 09/19
5. Describe the applicant’s current symptoms of AD/HD that cause significant impairment
across multiple settings and that have been present for at least six months. Provide copies of
any objective evidence of those symptoms, such as job evaluations, rating scales filled out by
third parties, academic records, etc.
6. Describe the applicant’s symptoms of AD/HD that were present in childhood or early
adolescence (even if not formally diagnosed) that caused significant impairment across
multiple settings. Provide copies of any objective evidence of those symptoms, such as report
cards, teacher comments, tutoring evaluations, etc.
ATTACH A COMPREHENSIVE EVALUATION REPORT. The provision of reasonable
accommodations is based on assessment of the current impact of the disability on the specific
testing activity. The Board of Bar Examiners generally requires documentation from an
evaluation conducted within the last three years to establish the current impact of the disability.
The diagnostic criteria as specified in the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) (or most current version) are used as the
basic guidelines for determination of an Attention Deficit/Hyperactivity Disorder (AD/HD)
diagnosis. The diagnosis depends on objective evidence of AD/HD symptoms that occur
early in the applicant’s development and cause the applicant clinically significant
impairment within multiple environments. Applicant self-report alone is generally insufficient
to establish evidence for the diagnosis. Please provide a comprehensive evaluation report that
addresses all five points below.
A. Sufficient numbers of symptoms (delineated in DSM-5) of inattention and/or
hyperactivity-impulsivity that have persisted for at least six months to a degree that is
“maladaptive” and inconsistent with developmental level. The exact symptoms should be
described in detail.
B. Objective evidence that symptoms of inattention and/or hyperactivity-impulsivity that
caused impairment were present during childhood.
Form 3-Page
4
Rev. 09/19
C. Objective evidence indicating that current impairment from the symptoms is observable
in two or more settings. There must be clear evidence of clinically significant impairment
within the academic setting. However, there must also be evidence that these
problems are not confined to
the academic setting. Explain how the impairment restricts
access to the bar exam and justifies the specific accommodation requests.
D. A determination that the symptoms of AD/HD are not a function of some other mental
disorder (such as a mood, anxiety, or personality disorder, psychosis, substance abuse,
low cognitive ability, etc.).
E. Indication of the specific AD/HD diagnostic subtype: predominantly inattentive type,
hyperactive-impulsive type, combined type, or not otherwise specified.
III. FORMAL TESTING
Psychological testing and self-report checklists cannot be used as the sole indicator of AD/HD
diagnosis independent of history and interview. However, such findings can augment clinical
data. They are particularly necessary to rule out intellectual limitation as an alternative
explanation for academic difficulty, to describe type and severity of learning problems, and to
assess the severity of cognitive deficits associated with AD/HD (inattention, working memory,
etc.).
1. Is there evidence from empirically validated rating scales completed by more than one source
that levels of AD/HD symptoms fall in the abnormal range? Yes No
If yes, please provide copies.
2. Is there evidence from empirically validated rating scales completed by more than one source
that the applicant has been significantly impaired by AD/HD symptoms? Yes No
If yes, briefly describe the findings.
3. Was testing performed that rules out cognitive factors as reasonable explanations for
complaints of inattention, distractibility, poor test performance, or academic problems?
Yes No
If yes, briefly describe the findings.
Form 3-Page
5
Rev. 09/19
4. Was testing performed that rules out psychiatric factors (anxiety, depression, etc.) or test
anxiety as reasonable explanations for complaints of inattention, distractibility, poor test
performance, or academic problems? Yes No
If yes, briefly describe the findings.
5. Was testing performed to assess the possibility that a lack of motivation or effort affected test
results? Yes No
Describe the findings, including the results of symptom validity tests.
IV. AD/HD TREATMENT
Is the applicant currently being treated for AD/HD? Yes No
If yes, describe the type of treatment, including any medication, and state the extent to which this
treatment is effective in controlling the AD/HD symptoms. If it is effective, explain why
accommodations are necessary.
If no, explain why treatment is not being pursued.
Form 3-Page
6
Rev. 09/19
V. ACCOMMODATIONS RECOMMENDED FOR THE MASSACHUSETTS BAR
EXAMINATION (CHECK ALL THAT APPLY)
The Massachusetts Bar Examination is a timed written examination administered in
three-hour sessions from 9:30 a.m. to 12:30 p.m. and from 2:00 p.m. to 5:00
p.m. on Tuesday and Wednesday as scheduled twice each year. There is a lunch break each day.
The first day consists of two performance tests (MPT) in the morning session and six essay
questions (MEE) in the afternoon session. The performance and essay questions are designed
to assess, among other things, the applicant’s ability to communicate his/her analysis
effectively in writing. Applicants may use their personal laptop computers to type their
answers, or they may handwrite their answers.
The second day consists of 200 multiple-choice questions (MBE), with 100 questions
administered in the morning session and 100 questions in the afternoon session. Applicants
record their answers by darkening circles on an answer sheet that is scanned by a computer to
grade the examination.
Applicants are assigned seats, two per six-foot table, in a room set for 200 to 1500 applicants.
They are not allowed to bring food, beverages other than water, or other items into the
testing room unless approved as accommodations. The examination is administered in
a quiet environment, and applicants are allowed to use small foam earplugs. They may leave
the room only to use the restroom or drinking fountain, within the time allotted
Taking into consideration this description of the examination and the functional
limitations currently experienced by the applicant, what test accommodation (or
accommodations, if more than one would be appropriate) do you recommend?
Test question formats:
Assistance:
Braille
Audio CD
Microsoft Word document on data CD for use with screen-reading software (for
MPT and MEE)
Large print/18-point font
Large print/24-point font
Reader
Typist/Transcriber for written portion (MPT/MEE)
Scribe for MBE
Form 3-Page
7
Rev.09/19
Explain your recommendation(s).___________________________________________________
Extra testing time. Indicate below how much extra testing time is recommended. Notre: for
applicants awarded 50% or 100% additional testing time for all session of the bar exam, the order
of the UBE will be MEE on Tuesday, MBE on Wednesday and Thursday and MPT on Friday.
Test Portion
Standard Time
Extra Time Recommended
(time and a half,
extra hour, 30 extra mins.)
MBE/Multiple-Choice
3 hours AM
3 hours PM
30
Off the Clock
60
90
Double
MEE/Essay
3 hours AM
3 hours PM
30
Off the Clock
60
90
Double
Explain why extra testing time is necessary and describe how you arrived at the specific amount
of extra time recommended. If either the amount of time or your rationale is different for
different portions of the examination, please explain. If relevant, address why extra breaks or
longer breaks are insufficient to accommodate the applicant’s functional limitations.
Other arrangements (e.g. lamp, lumbar support, magnifying items, medication, etc.).
Describe the recommended arrangements and explain why each is necessary.
MPT/Performance Test
30
Off the Clock
60
90
Double
__
__
__
Form 3-Page
8
Rev. 09/19
VI. PROFESSIONAL’S SIGNATURE
I have attached a copy of the comprehensive evaluation report and all records, test results,
or reports upon which I relied in making the diagnosis and completing this form.
I certify that the information on this form is true and correct based upon the information in my
records.
_____________________________________________ __________________________
Signature of person completing this form Date signed
_____________________________________________ __________________________
Title Daytime telephone number
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Commonwealth of Massachusetts Board of Bar Examiners - Form 3 - Attention DeficitHyperactivity Disorder Verification

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Completed 21 May 2020

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