Fillable Support for Students with Temporary Physical/Medical Conditions

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Support for Students with Temporary Physical/Medical Conditions

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Services for Students with Disabilities
Support for Students with Temporary Physical/Medical Conditions
Who Should Use This Form?
This form should be used only to request testing support for students with temporary impairments (caused by injury, accident, etc.)
who cannot postpone their tests. Use for the SAT, SAT Subject Tests, and AP Exams.
Students seeking testing supports for impairments that are not temporary must use SSD Online or complete the College
Board’s Student Eligibility Form to receive approval for testing accommodations.
For students taking AP Exams, if the temporary impairment will be resolved by the late testing dates, the AP Coordinator
should not seek temporary support. Instead, go to www.collegeboard.com/school and order an alternate exam for the
student (note ordering deadlines). In such cases, there is no additional charge for late testing.
Temporary support on the SAT is available only to seniors.
Important: If a student uses extended testing time or any other testing support without first receiving written authorization from the
College Board’s SSD office, that student’s test score(s) will not be reported.
Directions for SSD Coordinator (or other appropriate school official)
1. Complete Part 1. You will need information from the student’s doctor and teachers.
2. Enter your school code on all pages.
3. Give the student a copy of this form. The student must obtain written confirmation from his/her doctor regarding the
needed supports. Remind the student that the doctor must provide information pertaining to all items in Part 3 and that
the student and parent or guardian must sign Part 2. The student should return the signed form and documentation to you.
4. Collect a completed Teacher’s Survey Form (Part 4) from the student’s teacher(s). If the student is taking an AP Exam,
collect a Teacher’s Survey from each of the AP teachers in whose subject the student is taking an AP Exam. For the SAT,
include a Teacher’s Survey from the student’s core teachers. (Teachers may respond on a separate sheet as long as it
contains all information requested in Part 4, including the student’s name.)
5. Depending on the student’s physical/medical condition, additional documentation may be needed. Note: If the student is
requesting testing assistance for a concussion or head injury, copies of medical evaluation(s) and testing (e.g., ImPACT
testing or neuropsychological evaluation) must be included.
6. Fax the completed request form along with any attachments to (973) 735‐1900. If you are unable to fax, mail the request
form and documents to:
College Board Services for Students with Disabilities ‐ Temporary Supports
Educational Testing Service
1425 Lower Ferry Road
Ewing, NJ 08618
Time Frame
Submit this form and documentation as soon as the temporary impairment has been medically verified. The College Board will
expedite processing of temporary support forms. However, an appropriate review and determination cannot occur instantaneously.
Individuals who submit requests or information shortly before a scheduled College Board test should be prepared to be informed
that there was insufficient time to make a determination on their request. The College Board will reply by email or fax as soon as
possible.
Services for Students with Disabilities
Support for Students with Temporary Physical/Medical Conditions
PART 1: To Be Completed by School Official
Student Name: ___________________________________________ Date of Birth: _______________
Expected Date of Graduation (month/year): _______________ School Code: ____________
If
you don’t know your school’s code, look it up at http://sat.collegeboard.org/register/sat-code-search.
School Name: ________________________________________________________
City: _____________________________________________ State: ___________________
Specify the tests(s) and date(s) for which the student needs support (for SAT Subject Tests and AP Exams, indicate subject as well):
Exam Name: ______________________ Exam Date: _____________ Exam Subject: _________________________
Exam Name: ______________________ Exam Date: _____________ Exam Subject: _________________________
Exam Name: ______________________ Exam Date: _____________ Exam Subject: _________________________
Exam Name: ______________________ Exam Date: _____________ Exam Subject: _________________________
Describe the specific support requested:
Describe the injury/medical condition, including date of onset:
Name of school official completing form: _________________________________________ Title: __________________
Telephone: _______________ Fax: ____________________ Email: ______________________________
What is the best way to contact you? Telephone Fax Email
Signature of School Official: _____________________________________________________ Date: ________________
PART 2: Student and Parent/Guardian Signatures
Agreement below must be signed by the student and, if the student is under 18, the student’s parent/guardian before the request
can be processed.
I wish to request support on College Board test(s) for a temporary physical/medical condition. I give the College Board permission to receive and
review my records and to discuss my physical/medical condition and needs with school personnel and other professionals.
Student Signature: __________________________________________________ Date: __________________
Parent/Guardian Signature: ___________________________________________Date: ________________________
Services for Students with Disabilities
Support for Students with Temporary Physical/Medical Conditions
PART 3: Doctor’s Confirmation
Return to school official: __________________________ by ___________ (date). School Code: _______________
Attach a letter from the doctor that responds to ALL of the following statements (this request for support cannot be considered
unless each of the following items has been addressed):
1) Description of injury and degree of impairment.
2) Date of injury/onset of condition.
3) Expected date of recovery.
4) For students with hand/arm/wrist injuries:
a. If the student is in a cast or restraining device:
Indication of the area covered (a picture can be substituted).
The anticipated date of removal of the cast/device.
If the cast/device is removable, indicate when it must be worn and any restrictions during removal periods.
If the cast involves the hand, the degree of movement that is possible with the hands and fingers.
b. If a hand or arm is affected, is this the dominant hand/arm (i.e., the one with which the student customarily
writes)?
5) For students who are requesting testing assistance for a concussion/head injury, you must include:
a. Copies of a medical evaluation.
b. Copies of testing that has been completed (e.g., ImPACT testing or neuropsychological evaluation). Please note that
ImPACT testing is a brief screening measure, not a diagnostic instrument, and without other measures is not
sufficient to establish a need for support. If this is the only testing available, be sure to provide a detailed medical
evaluation.
c. Information regarding the student’s current condition, including:
i. Full description of the injury, including how the student was injured and whether the student lost
consciousness.
ii. Description of current symptoms, including frequency, intensity, and duration of current symptoms.
iii. Description of current medical restrictions, if any.
iv. If extended time is requested, information about the student’s ability to perform timed tasks.
Please note that concussions have a normal course of recovery and, therefore, documentation should include symptom
progression during and after the recovery phase.
The doctor’s confirmation must clearly indicate the doctor’s name, specialty, address, and phone number and must be signed and
dated by the doctor.
Services for Students with Disabilities
Support for Students with Temporary Physical/Medical Conditions
Part 4: Teacher Survey Form
Student Name: _________________________________ Return To: __________________________________________
Teacher Name: _________________________________ Subject/Class: _______________ School Code: ____________
To the teacher: The student named in Part 1 has requested temporary assistance for College Board tests. Your
detailed input
regarding his/her needs on classroom tests is valuable in our decision making process.
1. How long has the student been in your class? __________________________________________
2. OBSERVATION: Briefly describe your observations of the student’s condition and its impact during your class. Where
possible, provide specific examples. Include the frequency and severity of symptoms displayed during class.
3. SUPPORTS USED: What specific temporary supports are used by the student during classroom testing? Please indicate
which of these supports are used on a consistent basis.
4. EXTENDED TIME USED: If the student is provided extended time for classroom tests, how much additional time does he/she
generally use (e.g., 50%) to complete each of the following question types? (Note: Indicate time actually used, not the time
approved.)
a. Multiple‐choice test items: _____________________
b. Other question types, such as short-answer questions, essays, and math problems (Indicate the amount of additional
time used for each applicable type):
c. How does the student generally use the extended time (e.g., to complete test questions, to review completed test
questions, to take breaks, etc.)?
5. IMPACT: Describe the impact of the provided supports on the student’s performance. Does the student use the temporary
supports effectively? How does it change his/her performance on tests? What happens if supports are not provided?
Date: ______________ Signature: _________________________________________________________________
Contact the College Board at 212-713-8333 if you have questions.
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Support for Students with Temporary PhysicalMedical Conditions

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Completed 7 May 2021

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