Accommodation Request Form

Please complete this form after you have created an NHA account and scheduled your Exam Date with NHA. Have questions? Check out our Accommodations FAQs.

First name*

Last name*

Street address*

City*

State/Region*

Zip code*

Daytime Phone Number*

Email*

Registered NHA Exam Date?*

Please complete this form after you have created an NHA account and scheduled your Exam Date with NHA.

Year/Month/Day

Accommodations requested:*

If you are planning a test through Live Remote Proctoring (LRP), please note the only accommodation that may be granted is extended time. All other possible accommodations considered would need to be administered through either a PSI testing location on through an onsite test administration at your institution.

School or Employer Name

Name of my school or employer where I have attended my training program or where I am employed and who has provided authorization for me to take an NHA exam.

School or Employer Contact Email

Email address of person at my school or employer (where I am taking the exam(s)) that I am authorizing NHA to speak with about this accommodation request. If you prefer that NHA speak only with you about this request, please leave the name and email blank.

School or Employer Contact Name

Name of person at my school or employer (where I am taking the exam(s)) that I am authorizing NHA to speak with about this accommodation request. If you prefer that NHA speak only with you about this request, please leave the name and phone number blank.

School or Employer Contact Phone Number

Phone number of person at my school or employer (where I am taking the exam(s)) that I am authorizing NHA to speak with about this accommodation request. If you prefer that NHA speak only with you about this request, please leave the name and phone number blank.

PLEASE UPLOAD THE FOLLOWING DOCUMENTATION IN ORDER FOR NHA TO REVIEW YOUR REQUEST:

An IEP or acceptable 504 Plan (Please send the entire IEP/504 Plan).
-OR-
A letter from an objective qualified professional (i.e. Medical Doctor, psychiatrist, etc.) who can provide a diagnosis of your medical condition or disability. Mental/emotional diagnosis must be accompanied by a DSM classification code. An “objective” professional cannot be the candidate requesting the accommodation or a relative of the candidate.
1. The professional must provide a brief explanation of how your diagnosis prevents you from taking the exam under standard conditions.
2. If this is not a permanent diagnosis, the professional should include the first date diagnosis, approximate duration, and method used to make the diagnosis.
3. The professional must list the specific accommodations required
4. The letter must be on the professional’s letterhead, signed by the professional and dated.

Is the documentation you are including older than 5 years from today’s date?*

Letter from qualified professional, IEP or 504 Plan*

Must meet specifications above

Accommodation Form File #2 - optional

Accommodation Form File #3 - optional