New Accommodation form updated on 02/07/2024.
To provide equivalent access for all applicants taking the examination for Medi-Cal Peer Support Specialist certification, the testing interface has been designed to be accessible under the Web Content Accessibility Guidelines 2.1 AA (“WCAG 2.1AA”). The Web Content Accessibility Guidelines make Web content more accessible to people with disabilities. If the nature or extent of your disability is such that, despite WCAG 2.1 AA accessibility, you believe you will need special accommodations to complete the exam, you may request reasonable accommodations in accordance with the CalMHSA Reasonable Accommodations for Medi-Cal Peer Support Specialist Examination policy. Full compliance with the requirements is necessary to process reasonable accommodations requests.
To avoid any inconvenience, please ensure you have reviewed the Exam Comfort Aid List which comprises of items that do NOT require an accommodation request. If your request is listed in the Comfort Aid list, please do not submit an accommodation request, and proceed to schedule your exam.
Please have a qualified licensed medical provider complete this form and initial each accommodation requested. The information provided will be held in strict confidence. Please note that some accommodations may require the candidate to contact the test center directly to ensure accommodation is in place. This form is due to CalMHSA at least 30-days before the desired testing date, in accordance with policy.
Important Note: Do NOT schedule your exam appointment until all accommodations has been approved. If you have scheduled your exam, please cancel the appointment until your accommodation has been approved as the accommodations must be in place prior to scheduling the exam appointment.
Part 1: Candidate Information
Full Legal Name: _______________________________________________
Date of Birth: __________________________________________________
Email Address: _________________________________________________
Telephone Number: _____________________________________________
Exam Format Choice: ____Online ____In Person
I am requesting testing accommodations. I understand that my request must be supported by recent information as noted on this document from a qualified medical professional pursuant to CalMHSA’s Exam Accommodations Policy. I further understand that any cost related to collecting documentation is my personal responsibility; however, I will not bear any cost for approved accommodation(s) provided to me at a CalMHSA test site.
Candidate Signature: _____________________________ Date: __________
(electronic or manual signature accepted)
Part 2: Documentation of Eligibility for Reasonable Accommodations.
Please have this section completed by a qualified licensed medical provider.
I have evaluated: _____________________________ on Date: __________
(Patient’s Name)
In my capacity as a: _____________________________
(Professional Title)
The examination candidate listed above discussed with me the nature of the examination to be administered. I understand the exam is a 120 item, multiple-choice exam administered on a computer in an on-line format. Candidates have two and half (2.5) hours to complete the exam, with a ten (10) minute break approximately in the middle.
It is my opinion that, because of the candidate’s disability, the candidate should receive the testing accommodations as described below.
Provider must initial each accommodation requested: (All of these accommodations are for online and In-Person Testing unless otherwise specified)
___ Extended testing time (please select one of the following three options):
30 minutes [ET30MN]
50% of original time [ET12ET]
100% of original time [ETDBTM]
___ Beverage Permitted during testing. Beverages must be in a transparent spill-proof sports-like bottle with a sprout. [WATERB]
___Snacks allowed during testing. Must be in a clear, plastic bag. In-person exam must be delivered in a separate room [SNACKS]
___ Access locker (in-person exam only) Access to snacks, beverages, medication, or medical devices outside the testing space when approved to leave that space. Not permitted to access study materials, mobile phones or non-approved electronic devices during this time. [SNACK]
___ Frequent/extended breaks. The exam clock will continue to run. [FEBRK]
___ JAWS screen reader application* A screen reader software application that converts information on the screen to speech. [JAWTTS]
___ Ear plugs (online exam only). Ear plugs permitted in the testing room. No request is needed for in-person but must use the ear plugs issued at in-person center. [EARPMG]
___ Adjustable armless chair (in-person exam only) is provided in the testing room. Can be adjusted to improve access to the screen, keyboard, and mouse. [ADJARM]
___ Adjustable workstation (in-person exam only). Must be seated at the adjustable workstation. [ADJSTA]
___ May stand or alternate sitting and standing at adjustable workstation. The in-person exam must be delivered in a separate room. [STANDW]
___ May stand and move around as needed. In person exam must be delivered in a separate room. [SRMVE]
___ May read aloud. In-person exam must be delivered in a separate room. [SRRDMD]
___Separate room (in-person only). Exam must be delivered in a separate room [SEPRMM]
___Stool. A stool or footrest is permitted during testing. No request needed for medical foot stool, see Comfort Aid list. [STPST]
___ Adjustable contrast. Toggle option within the exam to change the colors of text and/or background at any time. [ADJCTR]
___ Adjustable font size. Toggle option within the exam to enlarge the screen at any time. [ADJFNT]
___ Screen Magnifier Only. Software application that allows for magnification greater than 200% and ability to change color of screen/text. Activated upon launching the exam. [ZTXTSM]
___ English Dictionary (in person only) is permitted in the testing room. Markings in the dictionary are not allowed.[ENGDCT]
___ English/Spanish Dictionary (in person only) is permitted in the testing room. Markings in the dictionary are not allowed. [ESPDCT]
___ Glucose meter and testing supplies permitted during testing. [GSMTR]
___ Liquid medication permitted during testing [MEDS2]
___ Sunglasses permitted during testing [SUNGMA]
___ Sign language interpreter**for communication with staff only. [ASDJR]
___ Nursing mother accommodation Permitted to access necessary medical equipment; may also be approved for additional time/breaks or to leave the testing area. [NMA]
___ Access to Nursing Mother Space (in-person exam only). Candidate will need a designated space to pump. May access necessary medical equipment to pump. [NMAWEB]
___ Admission Signature Not Required. Required if person is unable to sign during the admissions process. [NRSGNT]
___ Other Please specify [ACTHER ] ***:
__________________________________________________
___ Personal Assistant ****
(See next page to specify)
Personal Assistant Request(s)**** Please read carefully.
Following are the accommodations pertaining to the personal assistant request.
Medical provider must initial one of the options below.
Personal Assistant Type | Description | Initials |
Personal Assistant – Reader Only | Candidate will bring a personal assistant Reader that will be present during the exam to read directions and test questions. The Reader may not answer or explain any content-related questions. -In-Person Exam must be delivered in a separate room. -Online Exam will require the personal assistant to fill out two additional forms.1 |
______ |
Personal Assistant – Reader & Recorder | Candidate will bring a personal assistant Reader/Recorder that will be present during the exam to read directions and test questions. They will also input answers as dictated by the candidate. The Reader/Recorder may not answer or explain any content-related questions. -In-Person Exam must be delivered in a separate room. -Online Exam will require the personal assistant to fill out two additional forms. 1 |
______ |
Personal Assistant – Recorder Only | Candidate will bring a personal assistant Recorder that will be present during the exam to input answers only as dictated by the candidate. -In-Person Exam must be delivered in a separate room. -Online Exam will require the personal assistant to fill out two additional forms. 1 |
______ |
Personal Assistant – Sign Language Interpreter [SRSGNR] | CalMHSA will provide a Sign Language Interpreter that will be present to facilitate communication with test center staff and to sign test questions. The interpreter may not answer or explain any content-related questions. |
______ |
1 Online exam will require personal assistant to fill out two forms. Once we receive the request, additional forms will be provided.
Medical Provider Name: _________________________________________
License Number: ______________________________________________
Medical Provider Signature ________________________Date___________
Part 3: Important Information
* Use of screen reader application category: Candidates with a screen reader reasonable accommodation request must receive pre-approval by CalMHSA, prior to scheduling for the exam. The use of JAWS® screen reader software is required by Pearson VUE (proctor) for on-line and in-person testing. For on-line testing, candidates are responsible for having the JAWS screen reader software prior to the start of the exam. For in-person test, the JAWS® screen reader software is available at no-cost to candidate with pre-approval by CalMHSA. The candidate is responsible for knowing how to use the screen reader software. CalMHSA is not responsible for the provision of JAWS software or training on how to use the software. The proctor is NOT permitted to guide the candidate through how to use the screen reader software. Candidates must contact the proctoring agency (Pearson Vue) to confirm the reasonable accommodation, prior to the exam date. For more information on JAWS® software, cost and how to use it visit JAWS Screen Reader Accommodation page.
*** Details for “other” category: Specific information must be entered in this section. The information must be legible. CalMHSA shall review the accommodation requested and may contact the candidate directly for further inquiry. Candidates may be required to contact the proctoring agency (Pearson Vue) to confirm the reasonable accommodation, prior to the exam date.
*** Details for “Sign Language Interpreter” category: A sign language interpreter will be present to only facilitate communication with test center staff and will not be allowed in the testing room.
**** Personal assistant: A personal assistant is a person that will be present during the exam, to provide assistance with the accommodation as specified above. A personal assistant may not answer or explain any content-related questions. Except for the Sign Language interpreter, the candidate will provide their own personal assistant. In-person exam must be delivered in a separate room. For online exams, additional forms are required to be completed by the personal assistant prior to the candidate scheduling the exam. CalMHSA will provide the forms to candidates.
Part 4: Submission of Form.
- Request must be made using this form (return pages 1-4). Additional supporting documents may be submitted along with this form, if desired.
- Requests will be processed only for individuals with an approved application for examination.
- Request form pages 1-4 must be submitted to CalMHSA via email or by mail at least 30-days before the desired testing date. The 30-day timeframe starts from the date of the approval of the application for examination.
- Email address: [email protected]
- Physical address: 1610 Arden Way, Suite 175, Sacramento, CA 95815
- CalMHSA will review all complete reasonable accommodations requests and will notify the applicant of the status of the request for exam accommodations within 30 days from the date the request was made. Applicants will be notified via email on file on the application for examination.
If you have questions about this form, please contact us at [email protected] or call us at (279) 234-0699 during normal business hours, 8 AM – 5 PM, Monday – Friday, excluding holidays.
In the event the applicant disagrees with the decision, the applicant may file an appeal with the reason for disagreement. Please follow the appeals process guidelines located in the “Guidelines, Standards, and Procedures Manual.”
Part 5: Comfort Aid List
The list of items on the Comfort Aid list do NOT require an accommodation request, please review prior to submitting accommodation request.