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Form Doh 668-080 - Professional Evaluator Form For Applicant'S Disability-Based Accommodation For Examination(S) Page 3

7. How does the accommodation you selected relate to the applicant’s disability given the format

of the examination? Relate any comments to each exam for which any accommodation is

recommended.

__________________________________________________________________________

I certify that all of the information I have provided is true and correct.

_____________________________________________ __________________________________

Evaluator Name

Title

_____________________________________________ __________________________________

Business Name

Phone (enter 10 digit #)

_____________________________________________ __________________________________

Signature

Date (mm/dd/yyyy)

Once this form has been completed, send it to the address listed above or you can also return it to

the applicant to submit with their accommodation request. The board will not review the applicant’s

request until both forms have been received.

DOH 668-080 April 2013

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Form Doh 668-080 - Professional Evaluator Form For Applicant'S Disability-Based Accommodation For Examination(S) Page 3