You may qualify for double time or even unlimited time to complete this test. ADD, ADHD, or the like is nothing to be ashamed of.
Please contact us at Kweller Prep is you need professional assistance organizing all these forms. We assist a limited number of students each year, depending on our staff's availability.
Call 1(800) 631-1757
http://www.collegeboard.com/prod_downloads/ssd/sample_eligibility_form.pdf
LAST NAME (Family Name) - first 15 letters FIRST NAME - first 12 letters M.I.
NAME
(REQ’D FIELD)
Enter your legal name, including hyphens, apostrophes and spaces.
Omit suffixes such as Jr. or III.
2
5
6
Female Male
DATE OF BIRTH
(REQ’D FIELD)
POSTAL CODE
(Outside U.S. only)
COUNTRY CODE
(Outside U.S., U.S. territories, and Puerto Rico only)
SEX
(REQ’D FIELD)
Month Day Year
Student Eligibility Form
Student’s Signature: Parent/Guardian’s Signature: Parent/Guardian’s Name:
REQUESTED ACCOMMODATIONS
Indicate the accommodations that are being requested for the College Board tests below. Do not list accommodations that are not
needed for College Board tests, even if included in the IEP or 504 Plan. For assistance in filling out this section, and for additional information regarding specific accommodations,
refer to the guidance and definitions provided in the “Instructions for Completing the Student Eligibility Form,” or online at www.collegeboard.org/ssd.
For
parents and students to directly request accommodations on College Board Tests based on Disability (SAT®,
SAT Subject Tests®, Advanced Placement Program® Exams, PSAT/NMSQT®
). All requests must be accompanied
by documentation
. Do not staple anything to this form. Use black or blue ink to print information in the boxes and
to fill in the ovals. If you make a mistake, small amounts of white correction fluid may be used. Please print clearly
in capital letters.
Do not use a pencil. Complete both sides of this form. Mail completed form to the College Board
in the envelope provided. (Copies or faxes cannot be processed.)
12
13
4
7
8
MAILING ADDRESS
SOCIAL SECURITY NUMBER
SCHOOL YOU ATTEND
City
Line 1 (Street address or P.O. Box)
Line 2 (Apartment number if applicable)
State ZIP Code Home Telephone
( )
(REQ’D FIELD)
School Name:
Street Address:
(Not P.O. Box)
City: State:
STUDENT AGREEMENT:
I have read the College Board’s “Instructions for Completing the Student Eligibility Form” and wish to apply for testing accommodations on College Board tests based on disability. When
sections of the form are completed and signed by an official of the school identified in section 17 of the form, I authorize the school: to release to the College Board copies of my records that document the existence of my disability
and need for testing accommodations; to release any other information in the school’s custody that the College Board requests for the purpose of determining my eligibility for testing accommodations on College Board tests;
and to discuss my disability and accommodation needs with the College Board. I also grant the College Board permission to receive and review my records, and to discuss my disability and needs with school personnel and
other professionals. I agree to the conditions set forth in these Instructions and in the student bulletins for the SAT, AP
®, and PSAT/NMSQT Programs. I attest that all information I have provided on this form is true and accurate.
If your mailing address is outside the U.S. and you have a postal
code, fill in this oval and print your code in the space above.
Fill in the country code from the list in the “SAT Paper
Registration Guide” available in your guidance office or online
at www.collegeboard.org (go to SAT registration section).
COLLEGE BOARD
HIGH SCHOOL CODE
Find your school code online at
sat.collegeboard.org
or ask your
school counselor. Entering a HS code
authorizes us to send a score report
to your school. Students schooled at
home: enter 970000. Enter 935000 if
no longer in school.
9 10
EXPECTED
HIGH SCHOOL
GRADUATION DATE
DATE OF NEXT
INTENDED COLLEGE
BOARD TEST
11
PSAT/NMSQT
AP
SAT or SAT Subject
Month Year
Month Year
+100%*
(Double-time)
+50%
(Time and 1/2)
Greater than +100%*
a. Reading Time needed: + %
b. Written language expression Time needed: + %
c. Mathematical calculations Time needed: + %
d. Listening (Foreign language and music tests only) Time needed: + %
e. Speaking (Foreign language tests only) Time needed: + %
3
1. Extended Time
Indicate the amount of extended time requested for each test or section type. If requesting more extended time than currently
provided and used in school, you must indicate this. If you are not requesting extended time for a particular test type, leave that
section blank.
2. Breaks
Break time does not count toward testing
time (clock is “stopped”). If a configuration
not listed below is required, complete
item 6, “Other Assistance.”
Extra Breaks (between each section)
Extended Breaks (twice the length of
standard breaks)
3. Visual Assistance
If a required format is not listed below, complete item 6, “Other Assistance.”
Large print test book (14 point) Braille test (text, graphs, figures)* Magnifier Braille Writer *
Large print test book (20 point)* Magnifying machine* Enlarged (large-block) answer sheet (no “bubbles”/not scanned)
4. Auditory Assistance
(Do not choose both Reader and Cassette) Reader* Cassette Test* Braille graphs and figures (can be used with Reader or Cassette)*
5. Manual Assistance
(Do not choose both a computer and a writer/scribe)
Computer (word processor) for essays* (Note: Spell-check/grammar check are disabled)
Enlarged (large-block) answer sheet (no “bubbles”/not scanned) Writer/scribe to record dictated responses*
6. Other Assistance
Small group testing Permission for medication/food/drinks during test
Preferential seating (Specify: ) Written copy of oral instructions
Other (Specify: )
*
Accommodation requires School Testing for SAT tests. National Test Centers do not offer these accommodations.
NOT FOR OFFICIAL USE
6-digit High
School Code
87701-004633 • UNLPDF811
761222
Month Year
16
17
15
14
DISABILITY
What is the diagnosed disability? (Note all that apply)
LD (e.g., dyslexia, visual/auditory/language processing) Visual (specify):
Visual acuity:
(Measurements are: With correction Without correction)
ADHD Visual Field:
Hearing Physical (specify):
Autism (Not Asperger’s) Other impairment (specify):
(If this is the only disability)
ACCOMMODATIONS REQUESTED IN SECTION 13 PROVIDED AND USED ON SCHOOL TESTS (Must be completed)
All accommodations requested in section 13 have been provided and used on school tests for the past four school months and are included on the current IEP, 504 Plan or
Formal Written Plan/Program.
Some or all accommodations requested in section 13 have NOT been provided and used on school tests for the past four school months or are not included on the current
IEP, 504 Plan or Formal Written Plan/Program. In the box below, list the accommodations that are being requested that have not been provided, used, or included in
a school plan.
DOCUMENTATION
1. Formal Education Plan/Program Verification
a. Indicate the current school-generated formal education plan/program that is approved. (To be current, the plan/program
must be valid for the current school year.)
Current IEP No current formal plan is in place
Current 504 Plan Student has been declassified
Current Formal Written Plan/Program
b. What is the date the FIRST plan/program was approved (even if created at another school)?
(If there is no formal plan or the date is unknown, see “Instructions for Completing the Student Eligibility Form.”)
c. Indicate whether the date entered in response to 1.b. (date of first school plan) was more than 4 school months ago or less than 4 school months ago.
More than 4 school months ago Less than 4 school months ago
2. Evaluation Testing Verification
Additional assistance and references are provided in the “Instructions for Completing the Student Eligibility Form,” or online at www.collegeboard.org/ssd.
a. Is the testing to support the need for accommodation/s current? (Note: For academic testing, within 5 years; for psychiatric disabilities,
the annual evaluation update must be within 1 year; for visual, within 2 years; for physical/medical, within 1 year from the time of request.)
Yes No Does not apply (only for certain physical/visual conditions):
If yes, indicate date of most recent evaluation see instructions
(write in mm/dd/yy)
b. Indicate the most recent standardized tests used to document the existence of the disability and the need for accommodation/s.
(See “Instructions for Completing the Student Eligibility Form” for examples.)
Cognitive Ability Test (Test Name: )
Academic Achievement Test (Test Name: )
Documentation includes results from BOTH a cognitive ability and academic achievement test noted above.
Documentation does not include results from BOTH a cognitive ability and academic achievement test noted above.
Does not apply (only for certain physical/visual conditions). See “Instructions for Completing the Student Eligibility Form.”
Examiner’s name and title
Area of certification/license Date of evaluation
CONFIRMING INFORMATION AND SIGNATURE
PARENTS: LEAVE THIS SECTION BLANK.
SCHOOLS: If form is submitted by school, this section must be completed by school’s SSD coordinator or official school representative.
I verify that I have read the “Instructions for Completing the Student Eligibility Form” and that the accommodations requested above, unless
otherwise indicated in section 14, are provided and used on school-based tests, and that all the information provided is true and accurate.
Name:
Title:
Phone:
Fax:
Email:
Signature:
Date:
(Please print.)
© 2011 The College Board. All rights reserved. Advanced Placement Program, AP, College Board, SAT and the acorn
logo are registered trademarks of the College Board. SAT Subject Tests is a trademark owned by the College Board.
PSAT/NMSQT is a trademark of the College Board and National Merit Scholarship Corporation.
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