National League for Nursing

About the NLN

National League for Nursing - Test Products

REQUEST FOR SPECIAL TESTING ACCOMMODATIONS

School Administrators and Health Care Professionals:

This form must be completed and submitted to the National League for Nursing (NLN) along with the necessary documentation referenced in the ADA policy to support your testing accommodation request. To process your information efficiently, the NLN must receive all information at least two weeks in advance of your planned test date.

Please note: The information provided and any documentation regarding the examinee's disability and need for special testing accommodations will be considered strictly confidential and will not be shared with any outside source without the examinee's express written consent.

Examinee's Information
Last Name
First Name
Middle Initial
Social Security Number

School Information
School Name:
Address:
City
State: Zip Code

School Contact Information
Name of School Administrator:
Title:
Daytime Phone Number:
Fax:
Email:

Special Accommodations
Please provide (check all that apply)
Special seating or other physical accommodations
Large text/Magnified screen (if available) for examination
Reader
Extended testing time (normally 1.5 additional hours)
Separate testing area
Other special accommodations (please specify below)


Specify Test Title
Specify Test Type
RN or PN Pre-Admission
RN or PN Achievement (course)
RN or PN Pre-Licensure and Readiness
Nursing Acceleration Challenge Exam
Continuing Education Courses

Required Documentation from Health Care Professional (please check) :
Attached Not Attached

Signed
	(Indicate: School Administrator (SA), Health Care Professional (HCP))
Date

Return this form to:
NLN, Attn: Dr. Stephen Hetherman, 61 Broadway, 33 RD Floor, New York, NY 10006 Fax: 212-812-0393


Office Use
Special testing accommodations are:	Granted Denied
Signed
	Stephen Hetherman, EdD