NCEES HEALTHCARE PROVIDER FORM
Patient’s Full Name: ___________________________________
Patient’s Date of Birth: ___________________________________
Patient’s Telephone #: ___________________________________
Patient’s Email: ___________________________________
Purpose of this Form:
The National Council of Examiners for Engineering and Surveying (NCEES) is a private,
non-profit organization that develops standardized examinations. The examinations are
used by jurisdictions across the country to help evaluate the qualifications of individuals
who are seeking to become licensed professionals in the fields of engineering or
surveying.
The purpose of this form is to obtain information that will be relied upon by NCEES in
determining whether a licensure candidate needs testing accommodations because he or
she has a physical or mental impairment that rises to the level of a disability.
Accommodations are intended to level the examination playing field. Given the
important role that licensing exams play in protecting the health and safety of the
public, accommodations are warranted only when a candidate provides reasonable
documentation from a qualified professional who has diagnosed the candidate as having
a physical or mental impairment that substantially limits the candidate’s ability to
perform one or more major life activities that are relevant when taking an examination.
Instructions:
Please complete this form in a legible manner, sign it, and return it to the candidate
along with any test results, evaluation reports, or other documentation prepared as part
of your examination and evaluation of the candidate that you believe is necessary to
support the candidate’s accommodation request(s). The candidate will provide the form
and other documentation (if any) to NCEES.
If not already provided to you by the candidate, NCEES’s documentation guidelines for
specific types of impairments can be found at this web address:
https://ncees.org/exams/reasonable-accommodations/ada-exam-accommodations/
HEALTHCARE PROVIDER INFORMATION
(To be completed by qualified healthcare provider)
Name: Credentials and Licensing Information:
Address:
Phone: Fax: Email:
DISABILITY ASSESSMENT
1. What is the specific diagnosis? Please also provide the relevant DSM-5 or ICD code:
2. When was the diagnosis(es) made? 3. When did you last see the patient?
4. How did you make the diagnosis: What tools or methods were used to evaluate the patient
and his or her symptoms? If you and the patient are relying on assessment results to
support the patient’s accommodation request, please provide the results from any such
assessments that were administered in making your diagnosis.
5. Please describe the current symptoms this patient experiences as a result of the diagnosed
impairments(s), particularly as they relate to the patient’s ability to take a multiple-choice
examination and respond to essay questions under standard testing conditions.
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6. What major life activities are affected by the diagnosed impairment(s) and/or treatment
plan? (check all that apply)
☐ Caring for oneself ☐ Bending
☐ Performing manual tasks ☐ Speaking
☐ Seeing ☐ Breathing
☐ Hearing ☐ Learning
☐ Eating ☐ Reading
☐ Sleeping ☐ Concentrating
☐ Walking ☐ Thinking
☐ Standing ☐ Communicating
☐ Sitting ☐ Working
☐ Reaching ☐ Interacting with Others
☐ Lifting ☐ Operation of a major bodily function
7. What is the current treatment or medication plan?
8. Does the patient’s medication and/or treatment plan affect his/her ability to take a
multiple-choice examination under standard testing conditions? If so, how?
9. What testing accommodations do you recommend as a reasonable means of addressing
the patient’s symptoms?
By signing below, I am verifying that (1) the diagnosis(es) and supporting information
provided are accurate; and (2) I am a qualified professional who is licensed and properly
credentialed to diagnose and treat the stated conditions.
Healthcare Provider Signature: _____________________________ Date: ________
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MOBILITY ASSESSMENT SUPPLEMENT
(Complete only for conditions affecting patient’s ability to access physical spaces)
1. Is the patient able to climb or descend stairs? (check one)
☐ Yes
☐ No
2. Does the patient use an assistive mobility device, personal attendant, or service animal?
If so, please identify.
3. Does the patient have a current need for any of the items listed below?
(check all that apply)
☐ Adjustable chair
☐ Sit/stand desk
☐ Podium
☐ Other (please specify below)
By signing below, I am verifying that (1) the diagnosis(es) and supporting information
provided are accurate; and (2) I am a qualified professional who is licensed and properly
credentialed to diagnose and treat the stated conditions.
Healthcare Provider Signature: _____________________________ Date: ________
