Request disability accommodations for pharmacy licensing exams

Applicant Statement

• Description of your disability and how it impacts taking exams
• Your physician, therapist, or other health care practitioner (list additional practitioners on a separate sheet of paper and attach to the form)
  • Name
  • Office address
  • Length of time as a patient
• Type of accommodation you are requesting
• If you have previously been provided with test accommodations, please list the test provider(s) and describe the accommodations you received
• Witnessed and signed by a Notary Public

Practitioner Statement

• Practitioner name, title, office address, and phone number
• State license number (if applicable)
• Date of patient/applicant’s first consultation
• Date of patient/applicant’s last visit
• Diagnosis of disability and basis for diagnosis
• Recommended accommodation
• Practitioner's signature

College statement

• College name
• Description of the accommodation(s) given to the student at the institution
• Whether the accommodation was either:
  • A one-time event
  • An ongoing accommodation
• The information/documentation that was the basis for this approved accommodation
• School official’s signature