Certification Accommodation Request Form
Interactive Intelligence is dedicated to serving the needs of all of our students. If certification candidates are unable to take an Interactive Intelligence certification exam, either by using standard testing equipment or within the standard exam duration, Interactive Intelligence is committed to making all reasonable efforts to accommodate these candidates. You must submit this form two weeks prior to registering for an exam. Interactive Intelligence will respond to your request within two weeks of submission of the form. Applicant requesting accommodation(s) should complete Sections 1 and 2 of this form. An appropriate professional (education professional, doctor, psychologist, psychiatrist, etc.) must complete Section 3 of this form to certify that the applicant’s condition requires the requested test accommodations. The information requested below, and any documentation regarding the applicant’s need for accommodation in testing, will be considered strictly confidential and will not be shared without the applicant’s express written permission. Instructions for submission of the form This form and any documentation must be mailed to: Interactive Intelligence Education Services 7601 Interactive Way Indianapolis, IN 46278 Re: Accommodation Request Section 1 – Applicant Information Name Address (include city, state, postal code) Phone Number Email address Please list all examinations for which you are requesting accommodations: Signature: _________________________________________________ Date: _____________________ Page 1 of 3 Certification Accommodation Request Form
Section 2 – Requested Accommodations Please indicate what accommodations you are requesting, and provide a rationale for each: Accommodation: ______________________________________________________________________ Rationale: ___________________________________________________________________________________________ _______________________________________________________________________________ Accommodation: ______________________________________________________________________ Rationale: ___________________________________________________________________________________________ _______________________________________________________________________________ If you require more assistance in determining the accommodations necessary, please contact us at Edu.Exams@inin.com. Page 2 of 3 Certification Accommodation Request Form
Section 3 – Supporting Documentation Supporting documentation must be attached to this request form. This documentation must be signed by professional certifying the accommodation needs. Documentation is current if the assessment was completed within the last three (3) years. Documentation must: 1.
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Include a clear diagnosis. Document the history of impairment. Confirm the symptoms are not due to English‐as‐a‐second‐language (ESL) factors. Provide information on current functional limitations that are likely to affect the candidate’s ability to take the test under standard conditions. 5. Provide a specific rationale for each requested accommodation. Professional’s Name Professional’s Title License Number and Type (if applicable) Phone Number Email Address Signature: _______________________________________ Date: ___________________________ Page 3 of 3