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)
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