FORM B-AD/HD
MINNESOTA BOARD OF LAW EXAMINERS
TESTING ACCOMMODATIONS
STATEMENT TO BE COMPLETED BY PHYSICIAN OR LICENSED PROFESSIONAL:
Documentation of Attention Deficit Hyperactivity Disorder
Dear Doctor or Medical Professional:
Thank you for completing this form. The Board requires that an applicant with Attention
Deficit/Hyperactivity Disorder (AD/HD) be identified by a Comprehensive Diagnostic
Evaluation Report that addresses all of the points specifically inquired about in the summary
questions below. The Evaluation should:
1. Be completed or updated within the past 3 years.
2. Follow full, standard DSM-IV diagnostic criteria for AD/HD determination;
3. Provide evidence that diagnosis does not rely solely on self-report in establishing
developmental history, current symptoms and evidence of impairment.
Attach a copy of the Comprehensive Diagnostic Evaluation Report to this form.
Note: A showing of significant impairment in one or more major life activities is necessary in
order to be granted accommodations on the Minnesota bar exam.
(Please Type or Print Legibly)
Applicant Name:
Name of Licensed Physician or
Licensed Professional
Diagnosis
AD/HD predominantly inattentive type
AD/HD hyperactive/impulsive type
AD/HD combined type
Other
BACKGROUND/SUMMARY OF DIAGNOSIS
1.
What are the predominant current symptoms of AD/HD that result in academic impairment?
2.
How severe is that impairment when patient is using prescribed medications and/or
treatments?
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3.
In which, if any, of the patient’s other settings does AD/HD cause current impairment?
4.
Describe the patient’s impairments and state how severe they are.
5.
What academic problems did the patient experience in grade school?
High school?
College?
Law School?
6.
Does applicant have a developmental history of AD/HD? If yes, when and how did you
determine this?
If available, please attach copies of past evaluations addressing patient’s history of
diagnosis and treatment or past school or treatment records.
7.
Describe relevant family history.
8.
Have you conducted any external validation (such as record review, interviews, etc.) that
support a self-report of AD/HD symptoms and impairment?
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9.
Does the patient suffer from other illnesses, impairments or conditions that may impact
AD/HD symptoms?
If yes, what are those conditions and how do they impact the patient’s AD/HD symptoms?
10. In diagnosing this condition did you rule out any alternative explanations for patient’s
academic difficulty?
11. Was psychological/neuropsychological testing performed? If so, did results support the
described impairment?
12. If psychological/neuropsychological testing was not done, was it considered unnecessary?
Please submit psychological/neuropsychological test reports and/or findings relevant to
AD/HD diagnosis and determination of impairment associated with this diagnosis.
13. Is the applicant being treated for this condition?
14. What are the beneficial effects of treatment, if any?
14a. If not being treated, how was this decision made?
15. Do patient’s transcripts and previous achievement test scores support patient’s
academic/test-taking disability?
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16. If granted, how would requested accommodations ameliorate the impact of patient’s AD/HD
symptoms during test-taking?
I certify that all the information on this form is true and correct to the best of my knowledge and
belief.
I have attached to this Form B-AD/HD copies of all records in my possession or control on
which I have relied in answering the inquiries on this form. If I mail the records to the Minnesota
State Board of Law Examiners, I will direct them to the attention of:
Director, Minnesota Board of Law Examiners
180 E 5th Street, Suite 950
St. Paul, MN 55101
I understand this statement may be reviewed by a physician or licensed professional
retained by the Board of Law Examiners to assist the Board in determining what testing
accommodations will be granted, if any.
Signature of Licensed Medical Professional
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__________
Date
Rev. 6/08