NCCAOM^®

2001 K Street NW, 3rd Floor North,
Washington DC, 20006
Phone: 888-381-1140 | Fax: 202-381-1141

SCHOOL CONFIRMATION OF ADA ACCOMMODATION HISTORY

If a candidate for NCCAOM certification received accommodations during their formal education, the appropriate school official must complete this form to help the candidate receive the same accommodations at the Pearson VUE testing center for the NCCAOM National Board Exams.

This form has four (4) parts and must be completed in a single session. Once the “Submit” button at the end of the form is clicked, all data is saved and the form is received by NCCAOM staff.

Step 1 of 4

Candidate Information
Candidate name
First Last
Candidate address
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Phone
Name and address of school attended for acupuncture/Oriental medicine education

PART 2: School Disability Professional’s Contact Information

Following sections are to be completed by the person responsible for disability services.
Disability Professional's Name
First Last
Disability Professional's Title
School Name
School Address
Street Address Address Line 2 City State ZIP Code
Contact Phone
Fax
Email

PART 4: Verification
This institution or its disabilities services office has on file (or had on file at the time the accommodations were provided) documentation or diagnostic data confirming the candidate’s disability
- Yes
- No
Attestation and Digital Signature

I CERTIFY THAT THE INFORMATION PROVIDED BY ME ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AGREE, IF REQUESTED BY NCCAOM, TO SEND NCCAOM A COPY OF THE FILE OR OTHER DOCUMENTATION PERTINENT TO ESTABLISHING THE NEED FOR THESE ACCOMMODATIONS. I UNDERSTAND THAT THE APPLICANT AUTHORIZED THE RELEASE OF THIS INFORMATION AS PART OF THE APPLICATION PROCESS FOR REQUESTING ACCOMMODATIONS.

First Name Last name
Date
MM slash DD slash YYYY

NCCAOM^®

SCHOOL CONFIRMATION OF ADA ACCOMMODATION HISTORY

Step 1 of 4

Candidate Information

PART 2: School Disability Professional’s Contact Information

PART 3: Candidate’s Disability Status

Accommodations History

The following accommodations were provided to this candidate while he or she was a student at this institution (check all that apply)

PART 4: Verification

NCCAOM®

SCHOOL CONFIRMATION OF ADA ACCOMMODATION HISTORY

Step 1 of 4

Candidate Information

PART 2: School Disability Professional’s Contact Information

PART 3: Candidate’s Disability Status

Accommodations History

The following accommodations were provided to this candidate while he or she was a student at this institution (check all that apply)

PART 4: Verification

NCCAOM^®