Office of the Secretary of State
Department of Personnel
Testing Accommodation Request Form
This form must be completed by applicants requesting testing accommodation(s) due to a medical condition or disability.
Any request for accommodation testing based on a medical condition or disability must be supported by documentation
verifying the condition necessitating the request. All requested information must be provided.
This form must be submitted for each test for which an accommodation is being requested.
Submit this form(s) to the office where you will be testing. Do not attach this form to your applications(s).
Department of Personnel Department of Personnel
Rm. 196 Howlett Building 17 N. State St., Ste. 1300
Springfield, IL 62756 Chicago, IL 60602
Applicant Information
Name:________________________________________________________ Social Security Number: __________________________
Address: ______________________________________________________ Primary Phone Number: __________________________
City, State, ZIP: _________________________________________________ Secondary Phone Number: ________________________
Reason for Accommodation: _____________________________________________________________________________________
____________________________________________________________________________________________________________
Type of Accommodation Requested: _______________________________________________________________________________
____________________________________________________________________________________________________________
Are you testing for a specific job posting?
☐ YES
☐ NO
Date posting closes: ____________________________________________________________________________________________
Requisition Number for position (as indicated on posting notice): ________________________________________________________
____________________________________________________________________ _____________________________________
Signature of Applicant Date of Request
OFFICE USE ONLY — DO NOT WRITE BELOW THIS LINE
Request for accommodation: APPROVED ☐ DENIED ☐ Date: ________________________________________________
Notification of applicant: TELEPHONE ☐ LETTER ☐ Date: ________________________________________________
Alternative Accommodation: _____________________________________________________________________________________
_____________________________________________________ Scheduled Test Date: ___________________________________
Title:________________________________________________________________________________________________________
___________________________________________________________ ______________________________________________
Signature of Proctor Date Administered
Printed by authority of the State of Illinois. Julyr 2013 — 1 — Per D 174.2
