STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY …

STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY                         ARNOLD SCHWARZENEGGER, Governor



                                           CEMETERY AND FUNERAL BUREAU
                                               1625 North Market Blvd., #S-208
                                                    Sacramento, CA 95834
                                             (916) 574-7870 Fax (916) 574-8620




                                             DEPARTMENT OF
                                            CONSUMER AFFAIRS



                                Request for Examination Accommodations
                                     for Examinees with Disabilities




                                                Administered by the
                                           Department of Consumer Affairs
                                            Cemetery and Funeral Bureau




                                        GUIDELINES AND FORMS




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STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY                             ARNOLD SCHWARZENEGGER, Governor


                                           CEMETERY AND FUNERAL BUREAU
                                               1625 North Market Blvd., #S-208
                                                    Sacramento, CA 95834
                                             (916) 574-7870 Fax (916) 574-8620


                                        DISABILITY ACCOMMODATION
                                         REQUEST FOR EXAMINATION

         This questionnaire should be submitted by the final published application deadline. Requests
         must be supported by documentation certifying the disability from a qualified professional
         appropriate for evaluating the disability. Granting of a request for examination
         accommodations will be deferred until the necessary documentation is submitted. Mail
         your completed questionnaire and documentation to: DCA, Cemetery and Funeral Bureau, 1625
         North Market Boulevard, Suite S-208, Sacramento, California 95834


         PLEASE TYP OR PRINT.


         1. I am applying to take the                                 examination.

         2. Name (last, first, middle initial):

         3. Address:


              Street address


             City,                            State        Zip Code

         4. SSN:

         5. Date of Birth:

         6. What accommodation(s) are you requesting (please be specific)? Accommodation(s) must be
            appropriate to the disability.




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7. Nature of Disability:

       Chronic Health Problem                    Physical Disability
       Hearing Disability                        Visual Disability
       Learning Disability                       Other


8. In order to document your need for accommodation as completely as possible, please attach,
   in addition to professional documentation, a personal statement describing your disability and
   how it impairs your ability to accurately exhibit knowledge and skill on the examination.

9. Certification/Authorization:

   I certify that the above information is true and accurate. If test accommodations granted to
   me include a deviation from the standard testing time schedule, I agree that, from the time I
   begin the examination until I have completed it, I will not communicate in any way, to the
   extent possible, with any other individuals taking the examination and I will not
   communicate in any way with any such individuals about the content of the examination.


   Signature                                           Date:


   If clarification or further information regarding the documentation provided is needed, I
   authorize the state licensing authority to contact the professional(s) who diagnosed the
   disability and/or those entities which have granted me test accommodations. I authorize such
   professional(s) and entities to communicate with the state licensing authority in this regard to
   provide the state licensing authority with such clarification and/or further information.


   Signature                                           Date:




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STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY                                     ARNOLD SCHWARZENEGGER, Governor


                                           CEMETERY AND FUNERAL BUREAU
                                               1625 North Market Blvd., #S-208
                                                    Sacramento, CA 95834
                                             (916) 574-7870 Fax (916) 574-8620

                                     PROFESSIONAL VERIFICATION OF
                                     REQUEST FOR ACCOMMODATION

         The purpose of this form is to request your professional opinion concerning the disability and the
         accommodation requested. Please answer the two questions below and sign the certification. The
         opinion you provide will be used in evaluating this request.

         The information contained on this form will be treated as a confidential medical record except that
         examination proctors and providers may be informed regarding necessary modifications to examination
         procedures, and first aid and safety personnel may be informed, when appropriate, if the disability might
         require emergency treatment.

         PLEASE TYPE OR PRINT.

         NAME OF APPLICANT: ______________________________

         1. Please provide an evaluation and findings and describe the individual's functional limitations
            (attach additional sheets if needed).
            _________________________________________________________________________________
            _________________________________________________________________________________
            _________________________________________________________________________________

         2. Please provide specific recommendation(s) for examination accommodations, including a detailed
            explanation of why the accommodations are needed.
            _________________________________________________________________________________
            _________________________________________________________________________________
            _________________________________________________________________________________

         I certify under penalty of perjury under the laws of the State of California that I have the necessary
         specialized training to make the above diagnosis, that I personally examined the applicant named above,
         and that the diagnosis and assessment of accommodation request is my professional judgement. I
         understand that the Cemetery and Funeral Bureau may contact me (with the applicant's permission) to
         obtain further information if necessary, and that the Bureau may obtain an independent assessment by a
         second professional.

         ___________________________________                      _____________________________________
         Signature                                                Name of Institution or Practice
         ___________________________________                      _____________________________________
         Typed or Printed Name of Professional                    Street Address
         ____________________________________                     _____________________________________
         Title                                                    City, State, Zip Code
         ____________________________________                     _____________________________________
         Date                                                     Telephone Number (area code included)




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             How to Request Examination Accommodations




  1. Read the guidelines carefully.

  2. Complete the attached form titled, "Disability Accommodation Request
     for Examination." Please sign the form where indicated.

  3. Obtain professional verification of your disability on the attached form
     titled, "Professional Verification of Request for Accommodation."
     Note: If the request is limited to wheelchair space, or sitting in the front
     of the room, professional verification is not required.

  4. Attach a personal statement describing your disability, and how it impairs
     your ability to accurately exhibit your knowledge and skill on the examination.




Requests for examination accommodations must be received by the final
published application deadline.




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                      Guidelines for Examinees with Disabilities
                      Requesting Examination Accommodations

The Department of Consumer Affairs (DCA) provides reasonable and appropriate
accommodations for examinees with documented disabilities at no additional cost.

Examination accommodations are adjustments to the testing activity for an individual with a
disability in order to ease the effect of the disability on the examination process. Reasonable
accommodations vary according to the type and degree of the disability. Accommodations will
be made on an individual basis, and will depend on the nature and extent of the disability,
documentation provided, and the requirements of the examination.

Documentation
Applicants requesting reasonable accommodations because of disabilities must provide
appropriate documentation of the disability and specify the extent to which the standard
examination procedures need to be modified.

The following documentation should be submitted to support a request for accommodations:

1.     A completed Disability Accommodation Request for Examination, see
       attached form.

2.     A completed Professional Verification of Request for Accommodation, see
       attached form. This form is to be completed by a qualified professional to evaluate the
       disability and describe the applicant's condition and its severity. The form should
       include:
       a)      an evaluation and specific findings (relevant history, tests administered, test
               results and interpretation of those test results)
       b)      a description of the individual's functional limitations due to the stated disabilities
       c)      specific recommendations for examination accommodations including an
               explanation of why the accommodations are needed
       d)      name, address, telephone number and qualifications of each professional expert
               who provides documentation.

The DCA reserves the right to request further verification, if necessary, of the professional's
credentials and expertise relevant to the diagnosis being made. The DCA also reserves the right
to require further evaluation of the applicant by a professional of its choice at its expense.


Time for Submitting Documentation
An applicant must notify the DCA, Cemetery and Funeral Bureau in writing no later than the
final published application deadline that he or she has a disability and is requesting examination
accommodations. To accelerate the review process, applicants are urged to submit their request
and supporting documentation as early in the application process as possible.




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Examination Accommodations
Examination accommodations include but are not limited to the following:

                     Assistance in completing the answer sheet
                     Audio tape
                     Extended examination time
                     Extra or extended breaks (without extended testing time for the
                     examination
                     Individual testing room )for those whose disability necessitates separation
                     from all other examinees)
                     Large print examination
                     Printed copy of verbal instructions read by the proctor
                     Reader


Other accommodations will be considered upon request.


Application for Subsequent Test Accommodations
If there is additional or different accommodations being requested, documentation for the new
request must be submitted according to appropriate deadlines.




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