2015-2016 Private School Student
Accommodations Request Form
Students with disabilities may be provided allowable accommodations on Florida End-of-Course Assessments.
Please complete this form for a private school student needing accommodations on an EOC assessment, and
return it to Heather Himes, Senior Coordinator of Assessment, via fax (863-647-4709) or email
(heather.himes@polk-fl.net) no later than June 15, 2016 for approval.
District Name:
Private School Name:
Student Name:
Student Identification Number:
Student Grade Level:
Parent/Guardian Phone Number and Email Address:
Please select the administration and assessment(s) in which the student will participate. Then specify the student’s
disability and the accommodation(s) requested for the student.
Summer 2016 EOC Assessments
Algebra 1
Biology 1
Civics (MS only)
Geometry
US History (HS Only)
Algebra 2
Disability (as defined by Section 1003.01(3)(a), F.S., or subsection 6A-19.001(6), F.A.C.)
Please describe the student’s disability:
Accommodation(s) Requested
Flexible Presentation
Please describe:
Flexible Responding
Please describe:
Flexible Scheduling
Please describe:
Flexible Setting
Please describe:
Assistive Device(s) other than standard calculator
Please describe:
Is the requested accommodation(s) used regularly in the classroom for the student? Y/N
In order to receive an accommodation, the student’s official current Individual Education Plan (IEP) or
English Language Learner (ELL) status must be included with this form. This information MUST be faxed to
the Office of Assessment, Accountability, and Evaluation at 863-647-4709 by June 15, 2016.
Parent/Guardian Signature (Required)
Date
Private School Administrator Signature (Required)
Date