FORM 5: VISUAL 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 diagnostic evaluation by the qualified
professional who conducted an individualized assessment of the applicant and is recommending
accommodations on the Massachusetts Bar Examination on the basis of a visual disability. The
Board of Bar Examiners requires the qualified professional to complete all questions on this form
that pertain to the applicant’s visual impairment. Reference specific tests or other objective data
and clinical observations, and attach copies of test results, if relevant. 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 that pertain to the applicant’s visual impairment.
Return this completed form and copies of relevant test results to the applicant for
submission to the Board.
NOTICE TO APPLICANT: This section of this form is to be completed by you or
someone on your behalf in your presence
. The remainder of the form is to be
completed by the qualified professional who is recommending test accommodations on
the Massachusetts Bar Examination for you on the basis of a visual 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: ____________________
Signature of individual signing on behalf of applicant: __________________Date: _______
MASSACHUSETTS BOARD OF BAR EXAMINERS
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