Revised August 2008

Form Requesting Testing Accommodations Needing SDE Approval

Student Information (Please print clearly.)

_____________________________________________ ______________________
Student Name Date of Birth (m/d/yr.)
_____________________________________________ ______________________
State Student Identification Number (SSID) Grade
_____________________________________________ ______________________
Name of School Name of School System

Check all that apply.

_____ Individualized Education _____ 504 Plan _____ Limited English Proficient
Program (IEP) Plan (LEP/ELL)

Exceptionality(s): ______________________

Assessment: Check only one.

_____ Alabama Alternate Assessment (AAA)
_____ ACCESS for ELLs
_____ Alabama Direct Assessment of Writing (ADAW)
_____ Alabama High School Graduation Exam (AHSGE) ____ Spring ____ Summer____ Fall ____Winter
_____ Alabama Science Assessment (ASA)
_____ Dynamic Indicators Of Basic Early Literacy Skills (DIBELS) ____ Fall _____ Mid year ____ Spring
_____ Stanford Achievement Test/Alabama Reading and Mathematics Test (ARMT)

Reason for Request: ______________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________

Description of Accommodation Requested: ___________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________

Length of Prior Practice in Instructional Program and on Classroom Tests: _______________________

Justification: ____________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

___________________________________ ____________________________
IEP Team/504/LEP Committee Representative Date
___________________________________ ____________________________
System Special Education/504/LEP Coordinator Date
___________________________________ _____________________________
System Test Coordinator Date

Additional documentation needed:

1. Prior practice documented in IEP/504 Plan/LEP Plan.
2. Proof of prior practice daily in classroom.
3. Proof of success of requested accommodation.