Fillable United States Medical Licensing Examination (USMLE SUBSEQUENT REQUEST

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United States Medical Licensing Examination (USMLE SUBSEQUENT REQUEST

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Subsequent Request Form (6/2020) Pa ge 1 of 5
United States Medical Licensing Examination
®
(USMLE
®
)
SUBSEQUENT REQUEST FOR TEST ACCOMMODATIONS
Use this form if you were previously provided test accommodation(s) for a USMLE Step Exam
The National Board of Medical Examiners
®
(NBME
®
) processes requests for test
accommodations on behalf of the USMLE program
If you have a documented disability covered under the Americans with Disabilities Act (ADA), you must
notify the USMLE in writing each time you apply for a Step examination for which you require test
accommodations. Submitting this form constitutes your official notification.
• Complete all sections of this request form; submit the form and any required documentation to Disability
Services. In order to begin processing your request, you must have a completed registration for the
USMLE Step exam for which you are requesting accommodations.
• Do not resubmit supporting documentation already provided with a previous request.
• NBME will acknowledge receipt of your request by e-mail and audit your submission for completeness. If
you do not receive an e-mail acknowledgement within two business days of submitting your request,
please contact Disability Services at 215-590-9700, or disabilityservices@nbme.org.
• Some impairments change over time. You may be asked to submit updated documentation to complete
your request. The USMLE Guidelines for Test Accommodations at www.usmle.org provide a detailed
description of how to document a need for accommodation.
• Prior receipt of accommodations for a Step exam does not guarantee that identical accommodations
are indicated or will be available for all future Step examinations. For example, if you previously received
accommodations for Step 2 CS, and are requesting accommodations for Steps 1, 2 CK, or 3 for the first
time, your prior supporting documentation may not adequately document your need for accommodations
for a computer-based examination. Please carefully follow the instructions in Section D on pages 3-4 of
this form.
• Requests are processed in the order in which they are received. Processing cannot begin until
sufficient information is received by NBME and your Step exam registration is complete. Allow at
least 60 business days for processing of your request.
• The outcome of our review will not be released via telephone. All official communications regarding your
request will be made in writing. If you wish to modify or withdraw a request for test accommodations,
contact Disability Services by e-mail at disabilityservices@nbme.org or telephone at 215-590-9700.
USMLE
®
Subsequent Request for Test Accommodations
Subsequent Request Form (6/2020) Pa ge 2 of 5
Section A: Exam Information
Place a check next to the examination(s) for which you are currently registered and requesting test
accommodations: (Check all that apply)
Step 1
Step 2 Clinical Knowledge (CK)
Step 3
Section B: Biographical Information
Please type or print.
B1. Name:
_________________________________________________________________________________
Last First Middle Initial
B2. Date of Birth: _______________________
B3. USMLE # __ - __ __ __ - __ __ __ - __ (required)
B4. Address:
_________________________________________________________________________________
Street
_________________________________________________________________________________
City State/Province Zip/Postal Code
_________________________________________________________________________________
Country
_________________________________________________________________________________
Preferred Telephone Number
_________________________________________________________________________________
E-mail address
B5. Medical School Name: ___________________________________________________________
Country of Medical School:______________________ Date of Medical School Graduation:______
USMLE
®
Subsequent Request for Test Accommodations
Subsequent Request Form (6/2020) Pa ge 3 of 5
Section C: Request Accommodations for a Subsequent Exam
C1:
Do you require wheelchair access at the examination facility? Yes No
If yes, and you require an adjustable height computer table, indicate the number of inches required from
the bottom of the table to the floor: ________
C2. If you received accommodations for a previous computer-based USMLE exam (i.e., Step 1, Step
2 CK, Step 3), check the appropriate box below to request accommodations for subsequent computer-
based exam(s):
I am requesting the same accommodations previously provided for a computer-based USMLE
exam. (Additional break/test time for Step 2 CK will be over 2 days; Step 3 will extend the exam to
3-5 days depending on the requested accommodation. Contact Disability Services for information.)
I am requesting new/ different accommodations from those previously provided for a computer-
based exam due to a change in the nature or extent of my disability.
Describe the new/ different accommodation(s) you are requesting and the reason for the change:
________________________________________________________________________________________________
______________________________________________________________________________________________
_______________________________________________________________________________________________
Attach documentation of the change in your disability supporting your request for
new/different accommodations.
List the specific DSM/ICD diagnostic code(s) and disability for which you are requesting
new/different accommodations if there is a change from your previous request and report the year
that it was first diagnosed.
DIAGNOSTIC CODE DISABILITY YEAR DIAGNOSED
_______________ _________________________ __________
_______________ _________________________ __________
D1. If you received accommodations for a previous Step 2 CS exam and are making a request for a
computer-based exam for the first time, check the appropriate box below to request accommodations:
STEP 1: Check ONLY ONE box
Additional Break Time Additional Testing Time
Additional break time over 1 day 25% Additional test time (Time and 1/4) over 2 days
Additional break time over 2 days 50% Additional test time (Time and 1/2) over 2 days
100% Additional test time (Double time) over 2 days
Additional break time and 50% Additional test time (Time and 1/2) over 2 days
USMLE
®
Subsequent Request for Test Accommodations
Subsequent Request Form (6/2020) Pa ge 4 of 5
STEP 2 CK: Check ONLY ONE box
Additional Break Time Additional Testing Time
Additional break time over 2 days 25% Additional test time (Time and 1/4) over 2 days
50% Additional test time (Time and 1/2) over 2 days
100% Additional test time (Double time) over 2 days
Additional break time and 50% Additional test time (Time and 1/2) over 2 days
STEP 3: Check ONLY ONE box
Additional Break Time Additional Testing Time
Additional break time over 4 days 25% Additional test time (Time and 1/4) over 3 days
50% Additional test time (Time and 1/2) over 4 days
100% Additional test time (Double time) over 5 days
Additional break time and 50% Additional test time (Time and 1/2) over 4 days
Describe any other accommodation(s) you are requesting for Step 1, Step 2 CK, or Step 3.
____________________________________________________________________________________________
____________________________________________________________________________________________
List the specific DSM/ICD diagnostic code(s) and disability for which you are requesting
accommodations if there is a change from your previous request and report the year that it was first
diagnosed.
DIAGNOSTIC CODE DISABILITY YEAR DIAGNOSED
_______________ _________________________ __________
_______________ _________________________ __________
Attach documentation supporting your request for computer-based accommodations if your
previously submitted documentation was related to clinical skills related functioning.
Attach a brief updated personal statement describing how your impairment(s) substantially
limits your current functioning in a major life activity and how the standard examination
conditions are insufficient for your needs, and provide a rationale for why the
accommodations you are requesting are necessary in the context of this examination.
D2. Certification of Prior Test Accommodations
If you receive/received accommodations for written exams/classroom work in medical school, the
appropriate official at your school/residency must complete and submit the Certification of Prior
Test Accommodations form if not previously provided, available at www.usmle.org.
USMLE
®
Subsequent Request for Test Accommodations
Subsequent Request Form (6/2020) Pa ge 5 of 5
Section E: Certification and Authorization
To the best of my knowledge and belief, the information recorded on this request form is true and accurate. I
understand that my request for accommodations, including this form and all supporting documentation, must
be received by the NBME sufficiently in advance of my anticipated test date in order to provide adequate
time to evaluate and process my request.
I acknowledge and agree that any information submitted by me or on my behalf may be used by the USMLE
program for the following purposes:
• Evaluating my eligibility for accommodations. When appropriate, my information may be disclosed
to qualified independent reviewers for this purpose.
• Conducting research. Any disclosure of my information by the USMLE program will not contain
information that could be used to identify me individually; information that is presented in research
publications will be reported only in the aggregate.
I authorize the National Board of Medical Examiners (NBME) to contact the entities identified in this request
form, and the professionals identified in the documentation I am submitting in connection with it, to obtain
further information. I authorize such entities and professionals to provide NBME with all requested further
information.
I further understand that the USMLE reserves the right to take action, as described in the Bulletin of
Information, if it determines that false information or false statements have been presented on this request
form or in connection with my request for test accommodations.
Name (print): ____________________________________________
Signature: _______________________________________________ Date:_________________
Submitting Your Completed Request Form and Supporting Documentation:
(Do Not Send duplicate documents and Do Not Send by multiple methods as this will delay processing)
• Due to business restrictions in Philadelphia because of COVID-19 please submit
your request form and supporting documentation via E-mail or Fax.
• Requests sent to us via mail may be delayed
• E-mail: Maximum file size is 15 MB (including text in body of email, headers and
all attachments). Files larger than 15 MB may require separate emails. All
attachments must be in PDF format. Please scan your documents into as few
PDF’s as possible. Photographs of Personal Items may be in digital format such
as JPEGs/JPGs. We are not able to access embedded links.
• Fax or Mail: Submit your completed request form and supporting documents to
the address below once you register for your exam.
• DO NOT bind, staple, paper clip, or tab documents as this may delay processing.
Disability Services
NBME
3750 Market Street
Philadelphia, PA 19104-3190
Telephone: (215) 590-9700
Facsimile: (215) 590-9422
E-mail: disabilityservices@nbme.org
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United States Medical Licensing Examination (USMLE SUBSEQUENT REQUEST

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Completed 25 January 2022

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