Reasonable Accommodations Request Form

Instructions

The Patient Advocate Certification Board (PACB) provides reasonable accommodations in accordance with the Americans with Disabilities Act (ADA) to qualified candidates with documented disabilities.

All PACB exams are delivered remotely through a secure, live-proctored platform. Therefore, accommodations must be compatible with this format.

Please complete and submit this form at least 30 days prior to the start of your exam cycle. Incomplete requests or those submitted late may delay processing and may result in deferral to the next exam cycle.

Please do not attempt to schedule your examination until you receive an email about the status of your accommodation request and the next steps you must take to schedule your examination.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

For which exam cycle are you requesting accommodations

Spring 2026

Fall 2026

Section 2 - Disability Information

Nature of the disability

How does this disability affect your ability to take a remotely proctored, computer-based exam?

Section 3 - Requested Accommodations

Please check all accommodations you are requesting and provide details where indicated.

Extended time

Yes

Specify multiplier (e.g., 1.5x, 2x)

Additional Breaks

Yes

Specify frequency and duration

Screen magnification or zoom tools

Yes

Assistive Technology

Yes

Specify type and software name

Adjustable contrast or font size

Yes

Medical Device

Yes

Describe device and reason for use

Medication during testing

Yes

Specify medication and reason

Food or drink during testing

Yes

Specify items and medical reason

Positioning aids

Yes

Specify positioning aids and rationale (pillows, cushions, foot supports, etc.)

Other

Yes

Describe 'other' accommodation and reason

Section 4 - Supporting Documentation

Please attach documentation from a qualified healthcare professional that:

Identifies your disability or functional limitation(s);
Explains how it impacts your exam performance in a remotely proctored exam environment;
Recommends specific accommodations with a clear rationale.

Documentation must:

Be on official letterhead, signed, and dated;
Be issued within the past 3 years (or be accompanied by a current professional statement confirming the condition remains stable for permanent conditions).

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Section 5 - Certification and Signature

By signing below, I certify that:

The information provided in this form is true and complete;
I authorize PACB to contact my evaluator, if necessary, to verify information;
I understand that PACB may approve, modify, or deny requests based on documentation and technical feasibility;
I consent to PACB using this information only for the purpose of reviewing and implementing accommodations;
I understand that misrepresentation of disability status or misuse of accommodations may result in exam invalidation and disciplinary action.

Signature

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