Health & Wellness Coach Certifying Examination
Test Accommodations Information

Table of Contents
Overview and Instructions .............................................................................................................................. 2
Introduction ..................................................................................................................................................... 3
Guidelines to Request Test Accommodations .............................................................................................. 4
General Guidelines ……………………………………………………………………………………………….4
Documentation Guidelines for Certain Disorders ......................................................................................... 7
Specific Learning Disorder……………………………………………………………………………………….7
Attention Deficit/Hyperactivity Disorder (ADHD)….………..………………………………….……………….9
Visual Impairments………..….………………………………………………………………………………….10
Hearing Impairments…………………………………………………………………………………………….11
Psychiatric Disorders…………….………………………………………………………………………………12
Pre-Approved Items ……..……………………………………………...……………………………………………..14
Request for Test Accommodations Form …………………………………………………………………………..15
Certification of Prior Test Accommodations (CPTA) Form ....................................................................... 21

1

Overview and Instructions
To Request Test Accommodations
1. Carefully read these instructions, the General Guidelines and the specific guidelines that pertain to thereason for your request, if applicable.
2. Complete each section of the Request for Test Accommodations Form as instructed; sign and date theform.
3. Gather the required supporting documentation of the disability which supports you need foraccommodation.
• Compare your documentation with the information provided in the guidelines to ensure a complete
submission. Incomplete documentation may delay processing of your request.
4. Submit your request and supporting documentation.
• Create/go to your candidate account at www.MyNBME.org• Complete your exam registration• Indicate that you intend to request test accommodations by checking the box which will create an
Accommodations Request Case
5. Upload your completed request form and all supporting documents to your Accommodations Request
Case at www.MyNBME.org by the published deadline•••

Documents must be in the form of a Word doc or portable document files (PDF)
All documents should be digitized into 1 (one) PDF file and all pages should be in sequential orderand legible.
Do not include embedded web links to source documents

6. NBME Disability Services will acknowledge receipt of your request by email within a few business daysof receiving Accommodations Request Case. If you do not receive an acknowledgement within 2-3
business days after uploading your documents to your Accommodation Request Case, please contact
Disability Services directly.
Contact Information
Disability Services
National Board of Medical Examiners
3750 Market Street
Philadelphia, PA 19104-3102
Telephone: 215-590-9700
Fax: 215-590-9422
Email: access@nbme.org

2|PageIntroduction
Reasonable and appropriate accommodations are provided in accordance with the Americans with Disabilities
Act (ADA) for individuals with documented disabilities. The purpose of test accommodations is to provide
access to the examination. While presumably the use of accommodations will enable the individual to better
demonstrate his/her knowledge or skill, accommodations are not a guarantee of improved performance, testcompletion, or a particular outcome.
The ADA defines disability as a physical or mental impairment that substantially limits one or more major life
activities as compared to most people in the general population. Examples of major life activities include, but
are not limited to, walking, seeing, hearing, and learning.
Determination of whether an individual is substantially limited in functioning as compared to most people isbased on an individualized assessment of the current impact of the identified impairment. Supporting
documentation is necessary to determine what, if any, accommodations are appropriate for the disabledindividual in the examination setting and context. It is essential that supporting documentation provide a clear
description of the functional impairment and a rationale for the requested accommodation that is relevant to thesetting and context of the specific examination.
The following information is provided for examinees/candidates, evaluators, and others involved in the processof documenting a request for accommodations. Individuals requesting accommodations are welcome to sharethese guidelines with their evaluator, treating professional, and others so that appropriate documentation canbe assembled to support the request.

Confidentiality
All submitted disability related documentation is considered personal and confidential and is securely
maintained. Access to such information is limited to those individuals responsible for processing and reviewing
the documentation for the purpose of determining eligibility for test accommodations, including a professional
review by experts in the appropriate area of disability. No information concerning a request foraccommodations is released to a third party without a written request or consent from the individual, subject toany legal requirements to provide documents that NBME may have in its custody or control, and to thepossible need to disclose such information to attorneys or other third parties in the event of any disputes
relating to an accommodation decision.The following general guidelines are applicable to all disabilities and areprovided to assist you in documenting a need for test accommodations based on an impairment that
substantially limits one or more major life activities. Additional guidelines for documenting certain specificdisabilities are also provided below.

3|PageGeneral Guidelines
Requests for accommodations must include the following:
1. A completed and signed Request for Test Accommodations form
• Instructions and forms for requesting test accommodations are available at the examination program’s
webpage. https://www.nbme.org/taking-assessment/health-wellness-coaching Follow the instructions on
the appropriate form to initiate a request for accommodations. Requests made by a third party (e.g.,
evaluator, school, or employer) will not be accepted.
2. A personal statement• Provide a written statement describing the disability for which you are requesting accommodations.
o Include specific information about the disability-related symptoms and how they affect youracademic, occupational, social and other important areas of functioning.
oDescribe the extent to which your daily functioning is impaired and how that impairment interfereswith your ability to access the examination under standard conditions.

oProvide a clear rationale for the requested accommodation(s) and describe how each requested
accommodation will alleviate the functional limitations caused by your disability.

3. A report of professional evaluation and/or appropriate records from a qualified evaluator/treating
professional• Documentation from the evaluating or treating professional should be comprehensive and provide
specific evidence of impairment.
•

In most cases, the professional evaluation should have been conducted within the past three years.
More recent documentation may be necessary for relapsing-remitting conditions or conditions that canchange as a result of time or treatment (e.g., visual, neuromuscular, psychiatric impairments).

•

The evaluating professional should have training and direct experience in the diagnosis and treatmentof adults in the specific area of disability.

•

The diagnostic methods used should be appropriate to the specific disability and current professional
practices within the field. The evaluation report should adhere to current professional standards.

•

The qualified professional should provide their full name, professional credentials, current title, mailingaddress, e-mail address, and telephone number.

•

A comprehensive report of evaluation should include:o a description of the onset, frequency, intensity, and duration of relevant symptoms as well as theextent to which the symptoms impact your daily functioning across multiple environments (e.g.,social, academic, occupational, etc.);o a statement of the presenting problem and background history;o a description of the assessment procedure as well as specific diagnostic tests administered;o a detailed analysis and interpretation of the findings;
o actual results (e.g., scores) of all diagnostic procedures and tests utilized in the evaluation;
4|Pageooooif a diagnosis is indicated, the evaluator should describe a professionally recognized diagnosis
based on criteria outlined in the most current edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) or the International Statistical Classification of Diseases and Related
Health Problems (ICD);a description of the full extent of the individual's functional limitations due to the disability and how it
impacts the individual’s access to the examination under standard testing conditions;a description of the functional impact on physical, perceptual, and cognitive abilities in the context ofthe specific examination setting and format (e.g., computer-based examination; clinical or
performance-based examination) compared to most people in the general population;a clear rationale for the recommend accommodations and/or assistive devices.

•

Informal or non-standardized assessment methods, if used, should be described in enough detail that
other professionals in the field can understand their significance in the diagnostic process.

•If there is no prior history of accommodations, the qualified professional should describe why
accommodations have not been required or provided in the past and why they are needed for thisexamination.

4. Relevant objective records of impaired functioning• Objective records of functioning should be submitted to document the real-world current impact of thedisability and demonstrate how a major life activity relevant to the setting and context of the specificexamination is substantially limited.
•

Examples of supporting documentation include but are not limited to:o Prior clinical evaluations, diagnostic reports, treatment and/or educational plans, or other relevant
medical records.
oWritten feedback from teachers or supervisors.

o

Official academic records and transcripts.

oOfficial score reports for nationally normed standardized tests (e.g., SAT, ACT, MCAT, LSAT, GRE,
GMAT, professional licensing or certifying exams, etc.).

o

Performance evaluations from training programs, military service, or employment settings (e.g.,
part-time/full-time volunteer/paid jobs, clerkship/internship/residency, etc.).

o

Official records verifying approved accommodations from schools or other testing agencies listing
the specific accommodations approved and dates that they were provided.

5|PageALL Supporting documentation must be clear, legible and complete• Ensure that the documents you send are legible, particularly when submitted in electronic form (e.g.,
PDF files must be easily readable).
•

Reports and correspondence from professionals must be typewritten on official letterhead, dated, andsigned by the professional. Handwritten or unsigned letters from physicians or evaluators will not be
accepted.

•

Provide certified English translations of non-English documentation.

•

DO NOT SEND ORIGINAL DOCUMENTS: Send complete copies of original documents. NBME will
not return originals.

•

DO NOT SEND MULTIPLE COPIES OF DOCUMENTATION (e.g., email and mail copies of the same
documents)•

DO ensure that reports, transcripts, or other multipage documents are submitted with all pages intact.

Supplemental Documentation

Upon receipt, your submission will be audited for completeness. You will be notified in writing if the
documentation submitted in support of your request is insufficient for us to make an informed decision and you
will be offered the opportunity to supplement your request and supporting documentation.

Reconsideration

When our review is complete, you will be notified in writing of the decision. Individuals may request that NBME
reconsider its decision regarding test accommodations by submitting a signed and dated letter requesting
reconsideration accompanied by new substantive supporting documentation.

6|PageDocumentation Guidelines for Certain Disabilities
Specific Learning Disorder

In addition to the information described in the General Guidelines, a request for test accommodations on thebasis of a Specific Learning Disorder should include the following:

1. A report of evaluation by a qualified professional• A comprehensive psychological, psycho-educational, or neuropsychological evaluation that adheres tocurrent professional standards. It is up to each evaluator to determine an appropriate assessment
battery for any given evaluation.

•

The report of evaluation should generally include the following:o Relevant aspects of the individual’s developmental, family, medical, and other history including
linguistic history, if English is not the first language.
o

A summary of the individual’s educational history, experiences, and achievements, quality of
instruction, and language of instruction at each level, and trends in academic performance.

oHistory of prior academic interventions and classroom or test accommodations.

oA review of documentation from third-party sources when available (e.g., academic records; scoresfrom prior standardized exams; previous evaluations; feedback from teachers/faculty, tutors,
academic advisors, or others; etc.).

oData and information from a comprehensive battery of standardized, norm-referenced tests andmeasures used to assess the individual’s cognitive and academic functioning.
 The Nelson-Denny Reading Test (NDRT) and Wide Range Achievement Test (WRAT) are
not comprehensive diagnostic measures of achievement and therefore neither isconsidered acceptable if used as the sole measure of reading ability or academic skills.

oActual scores obtained for each subtest and/or measure administered reported as age-based
standard scores when available from the test publisher.

oThe specific version of each test (e.g., 4th Edition, etc.) along with the specific norms used forscoring (e.g., age-based norms).

oA summary integrating the obtained test and assessment data with relevant background/historicalinformation, previous and current manifestations of the learning impairment, and current academic,
occupational, and other life functioning.

oA differential diagnosis with discussion of how each possible alternative explanation for the learning
difficulty has been systematically ruled out (e.g., inadequate match between the individual's ability
and instructional demands; cultural or linguistic factors; poor motivation and/or study skills;
problems of attention, mood, or anxiety; sensory impairments; etc.)o

An explanation of how the specific area of impairment is relevant to the examination setting andcontext and how the standard conditions present a barrier to the individual’s access theexamination.

o

A rationale for each recommended test accommodation.
7|Pageo

If no prior history of classroom or test accommodations, an explanation of why accommodations
have not been required/provided in the past and why they are necessary at this time in the context
of the specific examination.

2. Objective records of impaired functioning• While historical records of childhood learning difficulties may not be obtainable in every case, providing
objective documentation demonstrating a history of academic impairment (e.g., reading, writing) isuseful to demonstrate the developmental nature and course of the impairment(s).

•Objective records that reflect current/recent academic, occupational, or other functional impairment that
demonstrate how a major life activity is substantially limited relevant to test taking. Refer to the General
Guidelines for examples of supporting documentation.

8|PageAttention-Deficit/Hyperactivity Disorder (ADHD)

In addition to the information described in the General Guidelines, a request for test accommodations on thebasis of ADHD should include the following:
1. A report of evaluation by a qualified professional• It is up to each professional to determine an appropriate assessment battery for any given evaluation.
•

The professional report should generally include the following:o Relevant aspects of the individual’s developmental, educational, family, medical, psychosocial,educational, occupational, and other personal history.
oA history of the individual's presenting symptoms, with detailed information about how thesymptoms have manifested in the home, school, work, and other settings over time.

oSelf-report symptom checklists, behavior rating scales, and continuous performance tests may be
useful in diagnosing ADHD. Since adult recall of childhood symptoms tends to be unreliable, theevaluator should seek ancillary information from other sources (e.g., parent, teacher, spouse) as
well as examples of current functional impairment in more than one setting.

o

A review of documentation from third-party sources, when available, to establish a history of
impairment that goes beyond self-report (e.g., review of academic records; scores from priorstandardized exams; previous evaluations or treatment records; feedback from teachers/faculty,
advisors, supervisors; etc.).

o

A differential diagnosis with a discussion of how each possible alternative explanation for theidentified problem(s) has been systematically ruled out.

oA rationale for each recommended test accommodation.

If the report includes a comprehensive psychological, psycho-educational, or neuropsychologicalevaluation, it should adhere to current professional standards and include: Actual scores obtained for each administered subtest and/or measure reported as age-based
standard scores when available from the test publisher.
 The specific version of each test (e.g., 4th Edition, etc.) along with the specific norms used forscoring (e.g., age-based norms).
 A summary integrating all obtained test and assessment data with available clinicalpresentation, behavioral observations, relevant background/historical information, and current
functioning to support the diagnostic conclusion.
If no prior history of classroom or test accommodations, an explanation of why accommodations havenot been required/provided in the past and why they are necessary at this time for this specificexamination.
o•

2. Objective records of impaired functioning• While historical records of childhood difficulties may not be obtainable in every case, providing objective
documentation demonstrating a history of functional impairment in more than one setting is useful todemonstrate the developmental nature and course of the impairment(s) due to ADHD.
•

Records of current/recent real-world functional impairment in academic, social, and/or vocationalsettings and in daily adaptive functioning demonstrating how a major life activity is substantially limited.
9|PageVisual Impairments

In addition to the information described in the General Guidelines, a request for test accommodations on thebasis of a visual impairment should include the following:
1. A report of evaluation by a qualified vision professional• Include a detailed discussion of how the specific symptoms and assessment results meet
professionally recognized diagnostic criteria for the identified visual impairment.
•

Include relevant history and course of the presenting symptoms and whether the condition is stableor could be expected to change over time.

•

Where relevant to the diagnosis and the examination for which accommodations are requested,comprehensive documentation should include detailed information about the health of the eye(s),visual fields, binocular functioning, accommodative functioning, oculomotor functioning, and otherpertinent information. Examples of such data include:o visual acuities (best-corrected for near and distance);o visual field print-outs;
o specific tests of accommodation (e.g., relative accommodation, amplitudes, facility, dynamic or
nearpoint retinoscopy);o specific tests of vergence (e.g., nearpoint of convergence, cover test, prism vergences, facility);o specific tests of reading eye movements (e.g., Developmental Eye Movement test, photoelectric oculogram)•

Include actual scores and results from all tests, procedures, measurements, and scales
administered to demonstrate the level of impairment to visual functioning.

•

Detailed information about what therapy, medication, and low-vision aids are being used to treat
the impairment, and the effectiveness of these interventions, including all relevant post-therapy
data.

•

A specific recommendation for all accommodations requested, including low vision aids, and an
explanation of how the accommodations will reduce the impact of the identified functional
limitations relevant to the specific examination setting and context.

2. Objective records of impaired functioning• Include objective records demonstrating how the visual impairment substantially limits
functioning relevant to the specific examination for which accommodations are requested.
•

Visual impairment in only one eye can often significantly impact the ability to perform threedimensional tasks. However, monocular conditions, in and of themselves, have not been shownto cause a substantial limitation in the ability to read or perform other two-dimensional tasks atnear. Therefore, requests for accommodations for computer-based tests based on visual
impairment in only one eye need to provide data to demonstrate reduced functioning in the
fellow eye, such as accommodation (focusing) or reading eye movements (saccades).

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Hearing Impairments

In addition to the information described in the General Guidelines, a request for test accommodations on thebasis of hearing impairment should include the following:
1. A report of evaluation by a qualified professional (e.g., audiologist, otolaryngologist)• Actual scores and results from all tests, procedures, measurements, and scales administered.
•

Information concerning the current impact of the hearing impairment on the individual’s daily life
functioning.

•

A statement about whether the hearing loss is static or changing and how the impairment is expected to
impact the individual’s ability to access the examination.

•

Detailed information about what therapy, assistive devices, or communication strategies are being used
to treat or ameliorate the impairment, and the effectiveness of these interventions.

•

A rationale for each recommended test accommodation relevant to the specific examination setting andcontext (e.g., for computer-based vs. clinical skills examinations).

2. Objective records of impaired functioning• A copy of the most recent audiogram or audiometric study that was conducted. Documentation should
ideally reflect the examinee’s audiologic functioning within the past year. Older documentation may besufficient for a hearing loss that is considered static in nature. Recent documentation (e.g., within thepast 6 months) may be needed for hearing impairments that are variable in course and expected tochange over time.
Assistive devices• Hearing aids and cochlear implants without Bluetooth/wireless capability enabled are considered
pre-approved personal items and are permitted in the secure testing facilities upon inspection by thetest center staff. Individuals do not need to request permission to use these personal amplification
devices, but should be prepared to show the item(s) to test center staff when checking in for their
examination.

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Psychiatric Disorders

In addition to the information described in the General Guidelines, a request for test accommodations on thebasis of a psychiatric disorder should include the following:

1. A report of evaluation by a qualified professional•

A comprehensive psychiatric or psychological evaluation should adhere to current professional
standards (e.g., the current version of the American Psychiatric Association’s Practice Guidelines for
the Psychiatric Evaluation of Adults) and should include the following:o A description of the presenting problem(s) and symptoms, with details about the onset and historyof symptoms, as well as their current frequency, severity, and duration, etc.
oInformation about the individual’s current daily life activities (e.g., school, working, home, social,etc.) and day-to-day functioning relative to most people.

oRelevant aspects of the individual’s history, with details regarding any past or present impact of
psychiatric symptoms on academic, occupational, and social functioning.

o

It is up to each evaluator to determine an appropriate assessment battery for any given evaluation.
Provide assessment data and findings from all diagnostic tests and measures administered.
Examples of common tests and measures include: Structured diagnostic interviews/clinical interviews (e.g., Structured Clinical Interview for DSM-5(SCID-5)).
 Standardized norm-referenced measures of cognitive or neuropsychological functioning.
Behavior or symptom rating scales (e.g., current versions of the Yale-Brown Obsessive
Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI), Multiscore Depression
Inventory for Adolescents and Adults (MDI), Beck Anxiety Inventory (BAI), Depression Anxiety
and Stress Scales 21, Minnesota Multiphasic Personality Inventory (MMPI), Conners’ Adult
Rating Scale, Achenbach Adult Self Report for Ages 18-59, Achenbach Behavior Checklist forAges 18-59, Clinical Assessment of Depression, Test Anxiety Inventory, or other scales foranxiety, mood, trauma, or related symptoms).
o Rating scales and other diagnostic instruments are not meant to be used in isolation; noone measure is considered sufficient by itself to make a psychiatric diagnosis.

Symptom severity indices.



Objective tests of effort (e.g., symptom validity tests).

•

A thorough summary that integrates test and assessment data with clinical presentation, behavioral
observations, relevant background/historical information, and current functioning.

•

Evidence of a differential diagnosis and a description of how each possible alternative explanation for
the identified problem has been systematically ruled out.
o For example, symptoms of the diagnosed psychiatric disorder must be distinguished from normal
adult reactions and behaviors such as test anxiety, academic underachievement or failure,bereavement, personality traits, or low self-esteem.

•

A specific diagnosis based on criteria for psychiatric disorders consistent with the most recent edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Statistical
Classification of Diseases and related Health Problems (ICD).
12 | P a g e•

A clear description of how the identified impairment and related symptoms are relevant to the specificexamination setting and context.

•

A rationale for each recommended test accommodation.

2. Objective records of impaired functioning• Records that reflect the individual’s functioning in daily life activities (e.g., social, academic,
occupational environments, etc.) since the onset of the psychiatric disorder and at the present time.
•

A report of evaluation or treatment summary completed within the past six (6) months is necessary toestablish the extent of current impairment and need for accommodations at the present time.

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Pre-Approved Items

Please visit the most up to date list of pre-approved personal items that are permitted in the secure testingarea subject to inspection by test center staff. If you have a medical need for one or more of these items during
your examination, you do NOT need to make a request or submit documentation to NBME for approval. Pleaseshow the item to test center staff when you check in for your examination. Some examples of pre-approved
items include:

Medicine and Medical Devices

Arm/shoulder sling
Bandages
Braces – neck, back, wrist, leg, or ankle
Casts/cervical collar
Cough drops (must be unwrapped and not in a bottle/container)
Earplugs (foam with no strings)
Epi-PenEye drops
Eye patches
Eyeglasses (without the case)
Glucose monitor
Glucose tablets
Handheld magnifying glass (non-electric, no case)Ice packs/heating pads
Inhaler
Medical alert bracelet
Nitroglycerin tablets
Pillow/lumbar support
Pills (must be unwrapped and not in a bottle/container)
Stool for elevating a limb
Surgical face mask
Walking boot casts
Medical Device Attached to a Person’s Body
CatheterColostomy bag
Continuous glucose monitor (CGM) and receiver (smart phones not permitted)
Heart rate monitor
Insulin pump
Oxygen tankSpinal cord stimulator
TENS units
Urine drainage bag
Communication Aids
Hearing aid/cochlear implant without Bluetooth/wireless capability
Vocal cord magnifiers
Mobility Devices
Cane
Crutches
WalkerWheelchair

If you have a medical condition that requires use of an item NOT on the above list, please make arequest for test accommodations.

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REQUEST FOR TEST ACCOMMODATIONS®

NBME processes requests for test accommodations for the
Health & Wellness Coach Certifying Examination (HWCCE)
If you have a documented disability covered under the Americans with Disabilities Act (ADA),
you must notify NBME in writing each time you apply for an examination for which you
require test accommodations. Submitting this form constitutes your official notification.
• Review the Guidelines to request test accommodations at www.nbme.org/HWC for a detailed description of
how to document a need for accommodations.
• Complete all sections of this request form and submit it together with all required documentation as soon
as possible after you register for your exam.
• Incomplete, illegible, or unsigned request forms and/or insufficient supporting documentation may delay
processing of your request.
• NBME will acknowledge receipt of your submission by e-mail. If you do not receive an acknowledgement
within a few days of submitting your request, please contact Disability Services at access@nbme.org or 215590-9700. Your submission will be audited for completeness and you may be asked to submit additional
documentation to support your request.
• Requests are processed in the order in which they are received. Allow at least 60 business days forprocessing of your request. Processing cannot begin until sufficient information is received by NBME andyour exam eligibility has been approved by NBHWC.
• The outcome of our review will not be released via telephone. All official communications regarding yourrequest will be made in writing. If you wish to modify or withdraw a request for test accommodations, contact
Disability Services by e-mail at access@nbme.org telephone at 215-590-9700

You MUST provide supporting documentation verifying your current functional impairment.
In order to document your need for accommodation, submit the following with this form:• A personal statement describing your disability and its impact on your daily life and educational
functioning.
• Supporting documentation such as psychoeducational evaluations; medical records; copies of report cards,
academic and score transcripts; faculty or supervisor feedback; job performance evaluations; clerkship/clinicalcourse evaluations; verification of prior academic/job/test accommodations; etc.
• A complete and comprehensive evaluation. Reports from qualified professionals must be typewritten on
letterhead, signed and include the professional’s qualifications.

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Section A: Biographical Information
Please type or print.

A1. Name:

Last

First

Middle Initial

A3. Date of Birth:
A4. Candidate ID #:(required)A5. Address:___________________________________________________________________________________
Street___________________________________________________________________________________City
State/Province
Zip/Postal Code___________________________________________________________________________________Country_____________________________________
Daytime Telephone Number__________________________________________
Alternate Telephone Number___________________________________________________________________________________
E-mail address

Section B: Accommodations Information
B1. 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 fromthe bottom of the table to the floor:
B2. Describe the accommodation(s) you are requesting. Accommodations must be appropriate to theimpairment within the context of the examination task and setting:

B3. If you are requesting additional testing time, check the box next to the accommodation you arerequesting. Check ONLY ONE box.
 25% Additional test time (Time and 1/4) over 1 day
 50% Additional test time (Time and 1/2) over 1 day
 100% Additional test time (Double time) over 1 day

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Section C: Disability
C1. List the specific DSM/ICD diagnostic code(s) and disability for which you are requestingaccommodations and report the year that it was first diagnosed.
DIAGNOSTIC CODEDISABILITY

YEAR DIAGNOSED________________________________________________________________________________________________________________________________________________________________________________________________________________________

C2. Personal Statement
Attach a signed and dated personal statement describing your impairment(s) and their impact
on daily life. The personal statement is your opportunity to tell us how your physical or mental
impairment(s) substantially limits your current functioning in a major life activity and how youraccess to the examination under standard conditions is impacted. In your own words, describe theimpact of your disability on your daily life and provide a rationale for why the specificaccommodation(s) you are requesting are necessary (do not confine your statement to standardized
test performance). Describe any modifications or accommodations that you are currently using tomanage day-to-day tasks in your home, occupational, or academic settings, which may be relevant
to taking a computer-based examination.

Section D: Accommodation History
D1. Standardized Examinations
List the accommodations received for previous standardized examinations such as college, graduate, or
professional school admissions tests and professional licensure or certification examinations (if noprevious test accommodations were provided, write NONE).

NAME OF EXAM __DATE(S)ADMINISTERED

ACCOMMODATION(S)_PROVIDED__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If accommodations were provided, attach official documentation from each testing agency
confirming the test accommodations they provided.
Attach copies of your score report(s) for any previous standardized examination taken.

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D2. Postsecondary Academic/Employment
List all formal accommodations you receive/received in the academic or employment setting and the dates
accommodations were provided:
If you receive/received accommodations at postsecondary school and/or work, please provide
written verification from the appropriate official at your school/place of work.

SCHOOL/EMPLOYER____ NAMEACCOMMODATIONSPROVIDEDDATESPROVIDED_____

Postsecondary School (college, graduate, professional school):

Employment Setting (paid or unpaid):

D3. Primary and Secondary School
List each school and all formal accommodations you received, and the dates accommodations were
provided:
Attach copies of official records from the school(s) listed confirming the accommodations they
provided.
ACCOMMODATIONSDATESSCHOOLPROVIDEDPROVIDED
High School

Middle School
Elementary School

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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 exam
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 e x am 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 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 exam program reserves the right to take action, as described in the Bulletin ofInformation, 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:

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What to Submit
 Legible PDF files or copies of all documents, not originals
 Typewritten and signed letters and reports from professionals on their letterhead Complete reports with all pages including test scores All documents in English. You are responsible for providing certified English translations of all
non-English documentation
 Childhood records - if your request is based on a developmental disorder (e.g., LD, dyslexia, ADHD) Official transcripts and standardized test score reports Documentation beyond self-report of your functional impairment
 Documentation of your functional impairment in activities other than test-taking
What NOT to Submit
 Handwritten or unsigned letters from physicians or evaluators
 Copies of reports with redactions or missing pages
 Duplicate documentation previously submitted to Disability Services
 Previous correspondence from Disability Services
 Research articles, your résumé or curriculum vita
Upload your completed Request for Test Accommodations Form and supporting documents
to your Accommodations Request Case at www.MyNBME.org when you register for yourexam.
Disability Services
National Board of Medical Examiners
3750 Market Street
Philadelphia, PA 19104-3190
Telephone: (215) 590-9700
Facsimile: (215) 590-9422
E-mail: access@nbme.org

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Certification of Prior Test
Accommodations
Please type or print. To be completed and signed by school official responsible forstudent disability services.
Applicant Name:
I certify that

Candidate ID#:
Name of School

officially approved and continuously

provided the following accommodations for the above applicant beginning on

1.

Date (Month/Year)

Accommodation(s) provided for classroom and clinical coursework:

Reason for accommodation(s):2. Accommodation(s) provided for written exams:_

Reason for accommodation(s):3. Accommodation(s) provided for clinical skills/performance exams:

Reason for accommodation(s):Name of School Official:

Print Name of Official

Signature of Official: ___Telephone Number: (Title:
Date:

Title of Official_)

Upload the completed form to your Accommodations Request Caseat www.MyNBME.org by the published deadline.
Direct questions to:
Disability Services
National Board of Medical Examiners
Telephone: (215) 590-9700
FAX: (215) 590-9422
E-mail: access@nbme.org
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