Checklist for Completing

Attention-Deficit/Hyperactivity Disorder
Testing Accommodations Request Form(s)

This checklist can be used to assist you, the GED testing candidate (or an advocate acting on behalf of the candidate), and the Chief Examiner
at your local GED Testing Center with instructions on how to properly complete the GED Testing Accommodations Request form.
You do not need to submit this form with your request for accommodations.

Candidate Last Name: _________________________________ Candidate First Name: ____________________________________

Candidate Social Security or Social Insurance Number: ________-_____-________
Be sure to ask the Chief Examiner at your local GED Testing Center any questions you may have about any part of the documentation/request
process that you do not understand.

• As of 09/01/05, The GED Testing Office no longer accepts forms L-15 or SA-001. Please obtain the appropriate disability form from your
local GED Testing Center or online at http://www.emsc.nysed.gov/ged/mods.shtml. The approved forms are: 1) Learning and Cognitive
Disabilities, 2) Attention-Deficit/Hyperactivity Disorder, 3) Emotional/Mental Health, and 4) Physical/Chronic Health Disability.

• Complete the GED candidate section (Section One) at the top of the request for accommodation form(s), providing complete
and accurate information in all areas of this section.
• Be sure to sign the candidate signature line of the request for accommodation form(s). If you are under the age of 18, a parent or
guardian must also sign.
• Be sure the professional diagnostician or advocate has completed all of the appropriate sections. Your advocate may assist
you by providing information from your medical and/or educational records onto your request for accommodations form(s). The
advocate can also sign on Section Three as long as the name of the professional diagnostician is listed.
• Letters are required from the specialist making the diagnosis. For Physical/Chronic Health and Emotional /Mental Health
accommodation requests, the letter must be less than 6 months old; for ADHD form, the letter must be less than 3 years old. The
letter must be on official letterhead and signed by the specialist making the diagnosis.

• Return your completed request for accommodations form(s) and all supporting documentation to the GED Chief Examiner at
the testing center where you will take your test.

• Provide the professional diagnostician, advocate or candidate with the appropriate accommodation request form, which can be
downloaded from http://www.emsc.nysed.gov/ged/mods.shtml.

• To assist with the application process, provide the candidate and/or advocate with all relevant resources (e.g., information on how to
complete the form, test schedules for your test center, brochures/pamphlets, etc.).

• The Chief Examiner must complete and sign Section Two before it is submitted to the GED Testing Office for review. The Chief
Examiner must review the entire form to ensure all information is complete and all relevant supporting documentation is attached.

If the Application Request has not been completed by the candidate, advocate, and/or diagnostician:
• Return application to professional diagnostician, advocate or candidate for additional information/documentation.
Provide the professional diagnostician, advocate or candidate with specific written directions for properly
completing the forms, including:
 Date returned: ___________________
 Items needed to complete the forms:_____________________________________________________________
When the request has been completed, mail the entire application to the NYSED GED Administrator. Date sent: _______________
Last Name: _____________________________________________ First Name: ___________________________________
Social Security or Social Insurance Number: ______-_____-_______ Birth Date: ____/____/________ Age: ____________
Address: ________________________________________________
City: ___________________________ State: ______________ Zip/Postal Code: _______________________________

Phone Number: ( ) -

Release of Information: If you are under 18 years of age, your parent or guardians signature is also required.
I grant permission to school officials and my healthcare provider(s) to release my education-related records and/or my medical or psychological
records to the GED Testing Service and its designees in connection with my request for testing accommodations.

Chief Examiner Name: __________________________________ 3 Digit SED Center Code: ________________________

Center Name: _________________________________________ 10 Digit GEDTS Center ID# ______________________
Phone Number: ( ) - Fax Number: ( ) - Email Address:

I have reviewed this application and confirm that it is complete.

Please indicate your role: Professional Diagnostician Advocate

Name of Professional Making Diagnosis (please print): _________________________________________________________________
Phone Number: ( ) - Date of Assessment: ____/____/__________________________
Licensure or Certification: ______________________________ Expiration Date: ____/____/_____________________________
State/Province: ___________ Number:________________ Specialty:____________________________________________
Name of Advocate (please print): __________________________________________________________________________________
Relationship to Candidate (please print): __________________________________Phone Number: ( ) -
Professional Making Diagnosis or Advocate’s Signature: _____________________________________Date: ______________________

ADD/ADHD- Page 1 of 4
 Request for Testing Accommodations
Attention-Deficit/Hyperactivity Disorder

Supporting documentation on professional diagnostician’s letterhead attached. (Required.)

DSM-IV Diagnosis Code: Indicate all that apply.

314.01 Attention Deficit/Hyperactivity Disorder, Combined Type

314.00 Attention Deficit/Hyperactivity Disorder, Predominantly Innattentive Type
314.01 Attention Deficit/Hyperactivity Disorder, Predominately Hyperactive/Impulse Type
314.9 Attention Deficit/Hyperactivity Disorder, Not Otherwise Specified

Functional Limitation(s):
______________________________________________________________________________________________
______________________________________________________________________________________________

Recommended Accommodation(s):
______________________________________________________________________________________________
______________________________________________________________________________________________

Rationale for Accommodation(s):

_____________________________________________________________________________________________

______________________________________________________________________________

ADD/ADHD- page 2 of 4
 Request for Testing Accommodations
Attention-Deficit/Hyperactivity Disorder

Extended Time (please specify): 1 ½ times 2 times Other:______________________________________

Audiocassette (tone-indexed) (requires extended testing time, generally double time)
2 times Other: ____________
The use of this accommodation requires practice. Candidates should have an opportunity to practice using an Official GED
Practice Test, Audiocassette Version prior to the scheduled testing date.

Braille
Scribe
Calculator for Part II
Talking Calculator for entire mathematics test.
Private room
Supervised Breaks (specify in minutes):
Uninterrupted testing time:________ minutes, break time:________ minutes

Other________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_____

General Educational Development (GED) Testing Service will not discriminate against candidates for testing on the basis of any legally
protected characteristic, including, but not limited to, race, color, religion, sex, sexual orientation, pregnancy, marital status, physical or mental
disability, age, veteran status, and national origin.

ADD/ADHD – page 3 of 4
 Approved for:

Extended Time (please specify): 1 ½ times 2 times Other: ________

Audiocassette (tone indexed) (requires extended testing time, generally double time)

2 times Other: ________

The use of this accommodation requires practice. Candidates should have an opportunity to practice using an
Official GED Practice Test, Audiocassette Version prior to the scheduled testing date.

Braille
Scribe
Calculator for Mathematics part II
Talking calculator for entire Mathematics Test
Private Room
Supervised Breaks (specify in minutes):
Uninterrupted testing time:________ minutes, breaks time:________ minutes
Other______________________________________________________________________________________

Returned for more information. Date Returned: ____/____/________

Reasons for returning request:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Request forwarded to GEDTS for review (explain reasons below) Date Forwarded: ____/____/________

Reasons for forwarding request to GEDTS for review:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

_____________________________ _(518) 474-2801___ __________________

GED Administrator's Signature Telephone Number Date

ADD/ADHD page 4 of 4