Application for ADA Assessment Accommodations
Purpose of this Form
This form must be completed by individuals requesting special accommodations for assessments under
the Americans with Disabilities Act (ADA). Before
completing this form, please review the supporting information on our website:
https://www.theabr.org/accommodations-for-people-with-disabilities
.
Forms must be submitted by the published deadline (see timelines on the above webpage) and include supporting documentation as described.
You must submit a new request for each assessment you wish to receive accommodations.
Contact Information
First Name
*
Last Name
*
ABR ID: 5-digit number (PXXXX for physicists) found on your certificate or any correspondence from the ABR
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
Phone Number
*
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For which assessment are you applying for accommodations?
ABR Discipline:
*
Diagnostic Radiology
Interventional Radiology
Radiation Oncology
Medical Physics
Initial Subspecialty
Assessment for which you are requesting accommodations:
*
OLA
Core Exam
Certifying Exam
Continuing Certification (MOC)
Assessment for which you are requesting accommodations:
*
OLA
Initial Qualifying (Physics, Biology, and/or Clinical)
Certifying (Oral) Exam
Continuing Certification (MOC)
Assessment for which you are requesting accommodations:
*
OLA
Initial Qualifying (Part 1 and/or Part 2)
Certifying (Oral) Exam
Continuing Certification (MOC)
Assessment for which you are requesting accommodations:
*
Neuroradiology
Nuclear Radiology
Pain Medicine
Pediatric Radiology
Continuing Certification (MOC)
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What type of accommodation are you requesting?
ADA
Military Related
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ADA Special Provision:
Hearing
Visual
Learning
Physical
Chronic Health Problem
Temporary injury
Other
What accommodation are you requesting? (i.e., additional time, special equipment, etc.)
*
Please attach documentation supporting your request for accommodations. * You must submit supporting documentation for any request. If you do not submit supporting documentation, your request may be denied. *
*
Select File
Cancel
of
Have you previously requested accommodations for an ABR assessment?
*
Yes
No
If yes, please specify the details of that accommodation request.
*
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What accommodation are you requesting? (i.e., additional time, special equipment, etc.)
*
Please attach documentation supporting your request for accommodations. * You must submit supporting documentation for any request. If you do not submit supporting documentation, your request may be denied. *
*
Select File
Cancel
of
Have you previously requested accommodations for an ABR assessment?
*
Yes
No
If yes, please specify the details of that accommodation request.
*
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Prior accommodations received
Have you previously received accommodations for any other assessment (i.e., NBME, FLEX, USMLE)?
*
Yes
No
For which assessment? (If multiple, enter most recent date)
Physician Licensure Exam (e.g., NBME, FLEX, USMLE)
Date
-
Month
-
Day
Year
Date
Medical College Admissions Test
Date
-
Month
-
Day
Year
Date
Other
Date
-
Month
-
Day
Year
Date
Please attach documentation of the accommodations you received (if available).
Select File
Cancel
of
Have you previously received educational accommodations (i.e., residency training, medical school, SAT)?
*
Yes
No
For what training?
Residency training
Medical School
Other
Briefly describe the accommodation(s) you received
*
Please attach documentation of the accommodations you received (if available).
Select File
Cancel
of
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OLA ADA Request
* For OLA ADA Request, you can only request additional time. You must submit supporting documentation for your request to be reviewed.
What accommodation are you requesting?
*
Please attach documentation supporting your request for accommodations.
*
Select File
Cancel
of
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By clicking "Submit", I acknowledge and agree that I bind and legally obligate myself to the same extent as I would by signing my name on a printed version of this form.
Signed: (please type your full name)
*
For questions or concerns please contact:
abradministration@theabr.org
.
Please allow up to two weeks for processing of your request. If you do not hear from us within that time, please email
abradministration@theabr.org
or call (520) 790-2900.
Submit
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