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:
Applicants 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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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 applicants condition
or impairment and to recommend accommodations.
II. DIAGNOSIS
1. What is the applicants current diagnosis? Include a statement as to whether the condition is
stable or progressive.
2. Please state the applicants best corrected visual acuities for distance and near vision.
III. DIAGNOSIS-SPECIFIC FINDINGS. ONLY ADDRESS RELEVANT AREAS.
1. Please describe the applicant’s eye health (both external and internal evaluations).
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2. Visual Field: threshold field, not confrontation (provide measurements and copies of reports)
3. Binocular Evaluation: eye deviation (provide measurements), diplopia, suppression, depth
perception, convergence, etc. Specify whether difficulty with distance, near point, or both.
4. Accommodative Skills: at near point, with and without lenses (provide measurements)
5. Oculomotor Skills: saccades, pursuits, tracking
IV. FUNCTIONAL LIMITATIONS
Describe the functional impact, if any, of the applicant’s visual condition on the applicant’s
reading ability.
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.
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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 or eight-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, provided by the Board of Bar Examiners. 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:
Braille
Assistance:
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
Typist/Transcriber for essay portion
Scribe for MBE
Explain your recommendation(s). _________________________________________________
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Extra testing time. Indicate below how much extra testing time is
recommended:
Test Port
ion
Standard Time
Extra Time Recommended
(30 extra minutes, extra hour, time and a half )
MBE/Multiple-Choice
3 hours AM
3 hours PM
MEE / Essay
3 hours AM
3 hours PM
60 90
30
Off the Clock
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.
VI. PROFESSIONALS SIGNATURE
I have attached a copy of 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
_____________________________________________
Title
__________________________
Date signed
__________________________
Daytime telephone number
30
60 90
Off the Clock
Double
60 90
30
Off the Clock
Double
MPT / Performance Test
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