Request For Testing Accommodations Form--revised

Revised August 2008

Form Requesting Testing Accommodations Needing SDE Approval Student Information (Please print clearly.) _____________________________________________ Student Name _____________________________________________ State Student Identification Number (SSID) _____________________________________________ Name of School

______________________ Date of Birth (m/d/yr.) ______________________ Grade ______________________ Name of School System

Check all that apply. _____ Individualized Education Program (IEP)

_____ 504 Plan

_____ Limited English Proficient Plan (LEP/ELL)

Exceptionality(s): ______________________ Assessment: Check only one. _____ Alabama Alternate Assessment (AAA) _____ ACCESS for ELLs _____ Alabama Direct Assessment of Writing (ADAW) _____ Alabama High School Graduation Exam (AHSGE) ____ Spring ____ Summer____ Fall ____Winter _____ Alabama Science Assessment (ASA) _____ Dynamic Indicators Of Basic Early Literacy Skills (DIBELS) ____ Fall _____ Mid year ____ Spring _____ Stanford Achievement Test/Alabama Reading and Mathematics Test (ARMT) Reason for Request: ______________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Description of Accommodation Requested: ___________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Length of Prior Practice in Instructional Program and on Classroom Tests: _______________________ Justification: ____________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________ IEP Team/504/LEP Committee Representative ___________________________________ System Special Education/504/LEP Coordinator ___________________________________ System Test Coordinator Additional documentation needed: 1. Prior practice documented in IEP/504 Plan/LEP Plan. 2. Proof of prior practice daily in classroom. 3. Proof of success of requested accommodation.

____________________________ Date ____________________________ Date _____________________________ Date