NDAEB Medical Accommodation Request Form

Page 1 of 4 Medical Accommodation Request Form If you are a candidate of the National Dental Assisting Examining Board (NDAEB) and you have requested an accommodation based on a disability (including, but not limited to, illness, injury, learning disability or medical condition) or a pregnancy/maternity related need, please complete section A below and bring this form to your treating physician or other qualified regulated health care professional. Forward the completed form to office@ndaeb.ca in PDF format. The completed form must be dated within 6 (six) months and must be received by the exam/CPE application deadline. Please note that a Medical Accommodation Request Form, completed in PDF format and dated within 6 months of the application deadline, will be the ONLY accepted form by the NDAEB in support of a medical accommodation request. For further clarity, applications for accommodation(s) submitted with only a medical note will be denied as well as if the Medical Accommodation Request Form exceeds the 6 (six) month timeframe. The NDAEB will assess each request for test accommodation on a case-by-case basis. The decision to grant an accommodation and the type of accommodation granted is at the sole discretion of the NDAEB. The decision and type of accommodation granted, if any, will depend on the nature and extent of your personal situation, the accommodation requested, the supporting documentation provided, and the setting, context and requirements of the specific examination/CPE. If the NDAEB decides to grant an accommodation, it will be valid only for one examination/CPE session. Separate accommodation requests must be made each time an accommodation is required for an examination/CPE. Note that all types of accommodations may not be available at every site or on every date. The NDAEB reserves the right to determine the date, location and time of examination/CPE sessions. If you have any questions about this form, please send a detailed email to office@ndaeb.ca or call (613) 526 3424. SECTION A (Completed by candidate) First name Middle name Last name Date of Birth (mm-dd-yyyy) Street address (or PO box) Suit/Apartment number City Province Postal code Email Phone number NDAEB Written Exam: March June September December Year________ OR NDAEB Clinical Practice Evaluation (CPE) date: ______________________ (mm-yyyy) RELEASE OF INFORMATION I am a candidate of the National Dental Assisting Examining Board (NDAEB). I have requested accommodation(s) based on a disability (including, but not limited to, illness, injury, learning disability or medical condition) or a pregnancy/maternity related need. The NDAEB requires certain information about my health and functional limitations in order to appropriately assess my request and manage my needs during the NDAEB Written Exam or Clinical Practice Evaluation (CPE). I,__________________________________________________________________________________________, hereby authorize (print your full name)

Page 2 of 4 the release of the information outlined in this form and any further documents, tests or assessment reports that are reasonably necessary to disclose. This authorization is based on the NDAEB Privacy Policy, and the information provided will be kept confidential and used only for the purpose stated above. I understand that the NDAEB reserves the right to determine whether my request for special testing accommodations will be granted and that I will be advised in writing of the decision. Candidate’s Signature_______________________________ Date_________________________________________________ (mm-dd-yyyy) NOTE TO QUALIFIED HEALTH CARE PROFESSIONAL: the NDAEB is the organization responsible for establishing and maintaining a national standard of competence for dental assistants in Canada. The NDAEB administers licensing examinations. Any accommodation(s) requested cannot modify the nature and level of the competencies being assessed or represent a fundamental alternation of the test. SECTION B (Completed by a qualified health care professional) HEALTH CARE PROFESSIONAL’S DESIGNATION Physician Nurse Practitioner Other (please specify) First Name Last name Name of Regulatory Body License Number Office/Organization Street address City Province Postal code Phone Number Fax Email Candidate’s name Date of last visit with the candidate I confirm that the candidate has a disability or a pregnancy/maternity related need that creates functional limitations that will affect their ability to complete the NDAEB Written exam or Clinical Practice Evaluation (CPE). Yes No SECTION C (Completed by a qualified health care professional) How long has the candidate been in your care? If the accommodation request is based on a disability, what type of disability is it (select all that apply) Cognitive Psychological Physical N/A (pregnancy/maternity related need) Other:_______________________________ (please specify)

Page 3 of 4 When was the candidate diagnosed with this condition? I diagnosed the candidate’s disability or am confirming their pregnancy/maternity-related needs: OR I did NOT diagnose the candidate’s disability. I confirm the diagnosis. The NDAEB Written exam is a computer-based multiple-choice exam, delivered over 4 hours at a Testing Center. Based on your knowledge of the candidate’s functional limitations, please indicate the accommodation(s) requested. The types of accommodation which the NDAEB may be able to provide if required, are set out below, however, this is not a comprehensive list of all accommodations which may be possible. Briefly explain how the candidate’s functional limitations will impact their ability to complete the NDAEB Written Exam under standard testing conditions. Please indicate below, in your professional capacity/opinion, why the candidate needs this accommodation. Please explain each that you selected. Extra time (time and one half = 6 hours) Separate room Text-to-speech software* (e.g. Kurzweil) Recorder** (in-person) Medical device (please specify - e.g. insulin pump, glucose monitor, insulin pen etc.) Other (please specify – e.g. emergency snacks, scrap paper, pencil, stress ball, noise cancelling headphones etc.) Do you have any additional comments that are relevant to the accommodation request? *Text-to-speech software is site specific and cannot be guaranteed. **If a Recorder is provided as a result of the request for special accommodation, the Recorder, the NDAEB and its agents “assume no liability” and “are not responsible” for ensuring the accuracy of the Written Examination and/or Clinical Practice Evaluation (CPE) results, and it is the candidate’s responsibility to ensure that the answers are recorded according to their instructions.

Page 4 of 4 SECTION D - DECLARATION (Completed by a qualified health care professional) I certify that the information I have provided is truthful and accurate to the best of my knowledge and is within my scope of practice. Printed name Signature Date Instructions to health care professionals: please complete the form and give it/email it back to the candidate. If you prefer to forward it directly to NDAEB, please email it to office@ndaeb.ca or Fax: (613) 526-5560. Medical stamp

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