Accommodations Request for the SAT and ACT

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Please make sure the student has submitted a consent form before continuing. If the student has not submitted a form yet, please have the student complete the ACT Consent to Release Information Form or the College Board Consent for Accommodations Request Form (for AP and SAT exams) before continuing.
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Please upload the SAT or ACT consent form.If you do not have access to the student's SAT or ACT consent form, please ask the HST to email the form directly to the school's SSD Coordinator (Linda Qian - linda.qian@sequoiagrove.org).
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What is the student's name?* This field is required.
First Name
Last Name
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What is the student's SSID?* This field is required.
0123456789
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Which school does the student attend?* This field is required.
Clarksville Charter School
Feather River Charter School
Lake View Charter School
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Who is the student's Guidance Counselor?* This field is required.North Counselors
Mary Buhr (students with last name A - C)
Wendy Maroun (students with last names D - H)
Rachel Radekin (students with last names I - M)
Jennifer Wright (students with N - Sh)
Michelle Bliss (students with last names Si - Z)
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Who is the student's 504 Coordinator or SPED Case Manager?* This field is required.
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Who is the student's Homeschool Teacher?* This field is required.
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What exam(s) does the student plan to sign up for?* This field is required.
ACT
AP
SAT
PSAT
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When does the student plan to take the exam(s)?If you don't know the exact date, please enter an approximate date.
Date
Year
Month
Day
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Is there a current school-generated formal educational plan/program (504 or IEP) that is approved for the student?* This field is required.(To be current, the plan/program must have been approved within the past 12 months.)
YESNO
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If there is a current formal education plan approved, please indicate the type of program.
Current IEP - Individual Education Program approved by the student's school that aligns with state IEP guidelines and/or the requirements of the Individuals with Education Act (IDEA).
Current 504 Plan - Formal education plan approved by the student's school that aligns with Section 504 of the Rehabilitation Act.
Current Qualified Formal Plan - Formal plan approved by the school, other than an IEP or 504, that meets the following criteria: Created by a group of people who know the student, understand the meaning of the evaluation results, and the available accommodations; and that was developed using tests or evaluations that 1) Are appropriate for the student's diagnosis and needs, 2) Were administered by those who meet state and/or professional guidelines for administering the evaluations and for diagnosing the disability in question, and 3) Demonstrate the student's disability and need for accommodations.
Current Formal Written Plan/Program - Formal education/medical plan approved by the school that is not covered by the above options.
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Please provide your best estimate of the date that the INITIAL (first ever) plan went into effect for the student, even if at another school.(NOTE: Estimate the approximate date of the student's FIRST plan, NOT current plan. For example, if this is the student's triennial evaluation, the student has had the plan in place for approximately 3 years. If this is a new student at your school, but the student had an IEP or 504 plan at the previous school, use the date of the prior school's plan.)
Yes, I know the specific date.
I am not sure of the date, but it was within the last 4 school months.
I don't know/remember the specific date or it was more than 4 school months.
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Please enter the specific date of the initial formal education plan.
Date
Year
Month
Day
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Please select the disabilities that apply.
Attention-Deficit/Hyperactivity Disorder, Combined Type
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type (ADD)
Attention-Deficit/Hyperactivity Disorder, Predominantly Impulsive/Hyperactive Type
AD/HD
Reading Disorder
Mathematics Disorder
Disorder of Written Expression
Learning Disorder Not Otherwise Specified
Learning Disorder
Autistic Disorder
Asperger's Disorder
Pervasive Development Disorder (PDD)
Autism Spectrum Disorders
Expressive Language Disorder/Speech Sound Disorder/Fluency Disorder
Language Disorder/Mixed Receptive-Expressive Language Disorder
Phonological Disorder (Documentation required)
Other Communication/Speech and Language Disorder (Documentation required)
Communication Disorder/Speech and Language
Deaf
Hard of Hearting
Central Auditory Processing
Other Hearing Impairment (Documentation required)
Hearing
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Please select the disabilities that apply.
Please Select
Please Select
Intellectual Disability
Intellectual Disability
Please Select
Please Select
Cerebral Palsy
Diabetes
Hydrocephalus
Spina Bifida
Sickle Cell Disease
Neurofibromatosis
Juvenile Rheumatoid Arthritis/Arthritis
Lyme Disease
Muscular Dystrophy
Guillain-Barre Syndrome
Crohn's Disease
Chronic Fatigue Syndrome
Cancer
Epstein Barr
Narcolepsy/Sleep Disorder
Epilepsy/Seizure Disorder
Traumatic Brain Injury
Orthopedic Impairment
Syncope
Other Physical/Medical Disorder (Documentation required)
Physical/Medical
Generalized Anxiety Disorder
Panic Disorder
Post-Traumatic Stress Disorder
Depression/Depressive Disorder
Bipolar Disorder
Obsessive-Compulsive Disorder
Schizophrenia Spectrum Disorder
Oppositional Defiant Disorder
Tourette's Syndrome/Tic Disorder
Emotionally Disturbed
Other Psychiatric Disorder (Documentation required)
Psychiatric
Please Select
Please Select
Blind
Legally Blind
Low Vision/Visually Impaired
Convergence Insufficiency
Other Visual Disorder (Documentation required)
Visual
Multiply Handicapped (Documentation required)
Other (Documentation required)
Dysgraphia (Documentation required)
Other
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Use this section to add any additional comments regarding disabilities.
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Does the student need extended time on the test?* This field is required.
YESNO
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Extended TimeIndicate the amount of extended time requested for each test or section type. Extended time should be used if the students need additional testing time. College Board assessments do not allow self-pacing therefore students will be required to sit for the entire duration of the extended time requested for each test or section type. If you are not requesting extended time for a particular test type, leave that section blank.
+50% (time & 1/2)
+100% (double time) (Documentation required)
Greater than 100% (Documentation required)
Reading
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Written Language Expression
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Mathematical Calculations
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Listening (Foreign language and music test only)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Speaking (Foreign language test only
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Reading
Written Language Expression
Mathematical Calculations
Listening (Foreign language and music test only)
Speaking (Foreign language test only
+50% (time & 1/2)
Row 0, Column 0
+100% (double time) (Documentation required)
Row 0, Column 1
Greater than 100% (Documentation required)
Row 0, Column 2
+50% (time & 1/2)
Row 1, Column 0
+100% (double time) (Documentation required)
Row 1, Column 1
Greater than 100% (Documentation required)
Row 1, Column 2
+50% (time & 1/2)
Row 2, Column 0
+100% (double time) (Documentation required)
Row 2, Column 1
Greater than 100% (Documentation required)
Row 2, Column 2
+50% (time & 1/2)
Row 3, Column 0
+100% (double time) (Documentation required)
Row 3, Column 1
Greater than 100% (Documentation required)
Row 3, Column 2
+50% (time & 1/2)
Row 4, Column 0
+100% (double time) (Documentation required)
Row 4, Column 1
Greater than 100% (Documentation required)
Row 4, Column 2
1 of 5
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If extended time was selected, please briefly describe how the student's disability causes the student to work more slowly than other students.
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Reading/Seeing TextPlease select any reading/seeing accommodations the student may need.
Large Print Test Book (If selected, please indicate font size)
Enlarged (Large Block) Answer Sheet (No bubbles/not scanned)
Human Reader
Prerecorded Audio
Braille
Magnifier (Documentation required)
Magnification Device (Documentation required)
Raised Line Drawings
Colored Overlay
Assistive Technology Compatible Test Form (Document required)
Other (Documentation required)
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Why does your student require this reading/seeing text accommodation?
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Large Print Test Book was selected, please indicate what font size the student will need.
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Recording AnswersPlease select any recording accommodations the student may need.
Enlarged (Large Block) Answer Sheet (No bubbles/not scanned)
Computer (Word Processor ONLY for essays ONLY)
Writer/Scribe to Record Responses (Documentation required)
Braille Writer
Record answers in test book
Other (Documentation required)
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Extra/Extended BreaksExtra/Extended breaks should be used for students who need more time "off the clock" in between testing sections or other exceptions to the standard break schedule.
Extra Breaks
Extended Breaks
Breaks As Needed (Documentation required)
Permission to Test Blood Sugar
Other (Documentation required)
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Modified SettingPlease select any modified setting accommodations the student may need.
Preferential Seating (If selected, please indicate where the student would like to sit)
Small Group Setting
School-Based Testing (Documentation required)
One-to-one testing (Documentation required)
Wheelchair Accessibility
Other (Documentation required)
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Preferential Seating was selected, please indicate where the student would like to sit.
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OtherPlease select any other accommodations the student may need.
Permission for food/medication
Written copy of oral instructions
Sign Language Interpreter for Oral Instructions ONLY
Assistive Technology (Documentation required)
Auditory Amplification/FM System
4-Function Calculator
Other (Documentation required)
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Are the accommodation(s) requested on the student's current 504 Plan or IEP? Please answer yes or no. If no, please explain why the accommodation is not listed.
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If you selected a field in which additional documentation is required, please upload the 504 Plan or IEP here. Or, you can also email the 504 Plan or IEP to Linda Qian (linda.qian@sequoiagrove.org).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Is there any other information you would like to share?
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Ok
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