Fillable Unique Accommodation Form

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Unique Accommodation Form

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  • 13 other fields

Country of origin: US
File type: PDF

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2020 PSSA/Keystone UNIQUE
ACCOMMODATION REQUEST
1. This accommodation is intended for those students with a severe disability that precludes
them from accessing and responding to instructional and assessment materials through
typical means, such as the hard copy test booklet or typical calculator.
2. The district and school are responsible for making the determination that the student is only
able to access the assessment through a unique accommodation.
3. The SAC must complete and submit this form to PDE at RA-accommodations@pa.gov.
Requests will not be considered without supporting documentation attached to this form.
4. Attach a redacted copy of the following parts of the current IEP; PA Secure ID, Present
Educational Levels, Specially Designed Instruction (SDI), & Part IV (State Assessment
section) of the IEP, or the accommodations page of the current 504 Plan.
5. Requests must be made no later than 8 WEEKS prior to the start of the testing window to
allow for review and response to the school district.
6. Members of the Bureau of Curriculum, Assessment, and Instruction and the Bureau of Special
Education will review the requests and notify the district of the results.
7. PDE may request the supporting documentation as needed for monitoring or as part
of a testing irregularity investigation.
8. Mark the accommodation on the demographics accommodations section.
District Name:
School Name:
Student PA Secure ID:
Student Grade:
Name/Title of Person Completing Request:
Phone Number:
Email Address:
Revised 10/2019 Unique Accommodation Form 1
1. Does the student receive special education services through IDEA?
YES NO
2. Does the student receive services through Section 504 of Rehabilitation Act of 1973?
YES NO
3. Does the student receive the accommodation regularly in classroom instruction?
YES NO
4. Is this accommodation documented in the student’s IEP or 504 Plan?
YES NO
5. This accommodation is needed for the following test(s):
PSSA ELA
PSSA Mathematics
PSSA Science
Keystone Literature
Keystone Algebra I
Keystone Biology
6. Name of requested software program (e.g., Dragon Dictate, Snap Type, Apple Dictate, etc.):
7. Name of device (e.g., iPad, laptop, Chromebook, desktop, Accent 1400, etc.):
8. Describe process of secure lock-down (e.g., Chrome Kiosk, Guided Access) Refer to
Supplemental Guidelines in the 2020 Accommodations Guidelines:
9. Describe testing environment (e.g., one-on-one setting):
10. Explain why this student needs this accommodation:
School Assessment Coordinator Signature (Required):
District Sp. Ed. Coordinator Signature (Required for students w/ IEP):
Principal Signature (Required):
District Assessment Coordinator Signature (Required):
Date of Request:
Revised 10/2019 Unique Accommodation Form 2
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Unique Accommodation Form

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Completed 24 July 2020

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