Fillable Commonwealth of Massachusetts Board of Bar Examiners - Form 4 - Psychological Disability Verification

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Commonwealth of Massachusetts Board of Bar Examiners - Form 4 - Psychological Disability Verification

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The Commonwealth of Massachusetts Board of Bar Examiners - Form 4 - Psychological Disability Verification form is 6 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 55 other fields

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File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

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FORM 4: PSYCHOLOGICAL DISABILITY 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 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 a psychological disability. The Board
of Bar Examiners requires documentation from an evaluation conducted within one year.
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 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 a psychological disability. 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 4-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. DIAGNOSIS AND CURRENT FUNCTIONAL LIMITATIONS
1. What is the applicant’s DSM-5 diagnosis? Please describe.
2. Describe the applicant’s history of presenting symptoms of a psychological disability.
Include a description of symptom frequency, intensity, and duration to establish severity of
symptomology.
Form 4-Page
3
Rev. 09/19
3. Describe the applicant’s current functional limitations caused by the psychological disability
in different settings and specifically address the impact of the disability on the applicant’s
ability to take the bar examination under standard conditions. Note: psychoeducational,
neuropsychological, or behavioral assessments often are necessary to demonstrate the
applicant’s current functional limitations in cognition.
4. Describe the applicant’s compliance with and response to treatment and medication, if
prescribed. Explain the effectiveness of any treatment and/or medication in reducing or
ameliorating the applicant’s functional limitations and the anticipated impact on the applicant
in the setting of the bar examination.
ATTACH A COMPREHENSIVE EVALUATION REPORT. An applicant’s
psychological disability must have been identified by a comprehensive diagnostic/clinical
evaluation that is well documented in the form of a comprehensive report. The report should
include the following:
• psychiatric/psychological history
• relevant developmental, educational, and familial history
• relevant medical and medication history
• results of full mental status examination
• description of current functional limitations in different settings
• results of any tests or instruments used to supplement the clinical interview and support
the presence of functional limitations, including any psychoeducational or
neuropsychological testing, rating scales, or personality tests
• diagnostic formulation, including discussion of differential or “rule out” diagnoses
•
objective evidence of how the psychological disability impairs the applicant's functioning
on the bar exam and restricts access.
Form 4-Page
4
Rev. 09/19
III. ACCOMMODATIONS RECOMMENDED FOR THE MASSACHUSETTS BAR
EX
AMINATION (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 for the test
session.
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 Version
Microsoft Word document on data CD for use with screen-reading software (for
essay
sessions)
Large print/18-point font
Large print/24-point font
Reader
Ty
pist/Transcriber for essay portion
Scribe for MBE
Form 4-Page
5
09/19
Explain your recommendation(s). __________________________________________________
Extra testing time. Indicate below how much extra testing time is recommended:
Test Portion
Standard Time
Extra Time Recommended
(30 extra mins., extra hour, time and a half)
MPT/Performance Test
3 hours AM
3 hours PM
30 60 90
Off the Clock
Double
MEE/Essay
3 hours AM
3 hours PM
30
60
90
Off
the Clock
Double
Explain why extra testing time is necessary and describe how you arrived at the specific amount
o
f 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., la
mp, lumbar support, magnifying items, medication, etc.).
Describe the recommended arrangements and explain why each is necessary.
MBE/Multiple Choice
30
60
90
Off the Clock
Double
Form 4-Page
6
Rev. 3/16
IV. 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 4 - Psychological Disability Verification

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Completed 18 May 2020

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