ACCOMMODATION REQUEST: COGNITIVE DISABILITY SCORE SHEET
Note to evaluators: The following tests are frequently used to demonstrate the impact of an individual’s impairment. If applicable, please provide
test scores by either using this form or, if you choose to use other tests, indicating the results on a separate page or in a separate report. Attach
this form or your report to the Accommodation Request: Medical Form (Form 2).
PRINT in capital letters or CLICK in the box to type.
Personal information
1
Candidate name
First
Candidate number
Middle
2
Last
Cognitive Assessment
Date cognitive assessment completed
Wechsler Adult Intelligence Scale — Fourth Edition (WAIS-IV) ___________ Full Scale
Verbal Comprehension Scale
Scaled Score
Perceptual Reasoning Scale
Similarities
Block Design
Vocabulary
Matrix Reasoning
Information
Visual Puzzles
Comprehension
Picture Completion
Scaled Score
Figure Weights
Working Memory Scale
Scaled Score
Processing Speed Scale
Digit Span
Symbol Search
Arithmetic
Coding
Letter-Number Sequencing
Cancellation
Scaled Score
Wechsler Adult Intelligence Scale — Fourth Edition (WAIS-IV): Attach full printout from the WAIS-IV Compuscore using age norms, standard
scores, and percentiles.
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Accommodation Request-Cognitive Disability Score Sheet
Achievement Assessment
3
Date achievement assessment completed
G:
H:
Nelson-Denny Reading Test Form:
Comprehension
Raw score
# of items completed
Scaled score
Percentile
Standard Time (current grade)
Standard Time (1st year college norms)
Extended Time
Woodcock-Johnson Psychoeducational Battery III: Tests of Achievement. Attach full printout from the WJ Compuscore using age norms,
standard scores, and percentiles (with Discrepancy Profiles).
Wechsler Individual Achievement Test III (WIAT-III): Attach full printout from publishing company.
4
Achievement Assessment
Other Tests Administered
All scores from all tests administered must be provided for the documentation to be considered complete. If they are not included on this form,
they should be attached as an appendix to the Accommodation Request: Medical Form (Form 2).
I certify that the information provided by me on this form and any attachments hereto is true and correct to the best of my knowledge.
Signature
License/Certification Number
Date
CPAWSB is committed to respecting your privacy and protecting your personal information. The personal information requested on this form is collected, used, and disclosed under
applicable federal and provincial legislation and CPAWSB’s policies and guidelines. The information will be distributed to and reviewed by members of the CPA Special Accommodations
Advisory Panel to assess eligibility for accommodations. Direct any questions about data collection and use to the CPAWSB Privacy Officer ([email protected]).
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Accommodation Request-Cognitive Disability Score Sheet