If you have a disability covered by the Americans with Disabilities Act, please complete this form andprovide the Documentation of Disability-related Needs on the next page so your accommodations fortesting can be processed efficiently. The information you provide and any documentation regarding yourdisability and your need for accommodation in testing will be treated with strict confidentiality. Please
return this form with your examination application and fee to PSI within 45 days of the desired testing date.
Candidate Information:Name (Last, First, Middle Initial, Maiden Name) ________________________________________________Name of Practice/Facility/Company __________________________________________________________
Title ____________________________________________________________________________________
Mailing Address __________________________________________________________________________
City ______________________________________________________ State _________ ZIP ____________
Daytime Phone Number ___________________________________________________________________
Email ___________________________________________________________________________________
Special Accommodations:
I request special accommodations for the Dental Anesthesia Assistant National Certification Examination (DAANCE).
Please provide (check all that apply):q Readerq Extended testing time (time-and-a-half )q Reduced distraction environmentq Other special accommodations (please specify) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Comments ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signed ___________________________________________________________ Date __________________
Return this form with your examination application and fee to:detach here "PSI
18000 W. 105th St.
Olathe, KS 66061-7543

20

If you have questions, call Candidate Services at 833-333-4755.

Request for Special Examination Accommodations

Request for Special Examination Accommodations

Please have this section completed by an appropriate professional (education professional, physician,psychologist, psychiatrist) to ensure that PSI is able to provide the required examination accommodations.
Professional Documentation:
I have known ____________________________________________ since ____ / ____ / ____
in my capacity as a ________________________________________________________ (Title).
The candidate discussed with me the nature of the examination to be administered. It is my opinion that,
because of this candidate’s disability described below, he/she should be accommodated by providing thespecial arrangements listed on the Request for Special Examination Accommodations form.
Description of Disability___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signed ______________________________________________________________________________________
Title _____________________________________________________________ Date ______________________
Printed Name ________________________________________________________________________________
Address _____________________________________________________________________________________
Phone Number ________________________________ License # (if applicable) __________________________
Return this form with your examination application and fee to:
PSI
18000 W. 105th St.
Olathe, KS 66061-7543
If you have questions, call Candidate Services at 833-333-4755.

detach here "Documentation of Disability-Related Needs

Documentation of Disability-related Needs

21