Form Per D174 "Testing Accommodation Request Form" - Illinois

What Is Form Per D174?

This is a legal form that was released by the Illinois Secretary of State - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Illinois Secretary of State;
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Download a fillable version of Form Per D174 by clicking the link below or browse more documents and templates provided by the Illinois Secretary of State.

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Download Form Per D174 "Testing Accommodation Request Form" - Illinois

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Office of the Secretary of State
Department of Personnel
Testing Accommodation Request Form
This form must be completed by applicants requesting testing accommodation(s) due to a medical condition or disability.
Any request for accommodation testing based on a medical condition or disability must be supported by documentation
verifying the condition necessitating the request. All requested information must be provided.
This form must be submitted for each test for which an accommodation is being requested.
Submit this form(s) to the office where you will be testing. Do not attach this form to your applications(s).
Department of Personnel
Department of Personnel
Rm. 196 Howlett Building
17 N. State St., Ste. 1300
Springfield, IL 62756
Chicago, IL 60602
Applicant Information
Name:________________________________________________________ Social Security Number: __________________________
Address: ______________________________________________________ Primary Phone Number: __________________________
City, State, ZIP: _________________________________________________ Secondary Phone Number: ________________________
Reason for Accommodation: _____________________________________________________________________________________
____________________________________________________________________________________________________________
Type of Accommodation Requested: _______________________________________________________________________________
____________________________________________________________________________________________________________
Are you testing for a specific job posting?
☐ YES
☐ NO
Date posting closes: ____________________________________________________________________________________________
Requisition Number for position (as indicated on posting notice): ________________________________________________________
____________________________________________________________________
_____________________________________
Signature of Applicant
Date of Request
OFFICE USE ONLY — DO NOT WRITE BELOW THIS LINE
Request for accommodation: APPROVED ☐
DENIED ☐
Date: ________________________________________________
TELEPHONE ☐
LETTER ☐
Notification of applicant:
Date: ________________________________________________
Alternative Accommodation: _____________________________________________________________________________________
_____________________________________________________
Scheduled Test Date: ___________________________________
Title:________________________________________________________________________________________________________
___________________________________________________________
______________________________________________
Signature of Proctor
Date Administered
Printed by authority of the State of Illinois. Julyr 2013 — 1 — Per D 174.2
Print
Reset
Save
Office of the Secretary of State
Department of Personnel
Testing Accommodation Request Form
This form must be completed by applicants requesting testing accommodation(s) due to a medical condition or disability.
Any request for accommodation testing based on a medical condition or disability must be supported by documentation
verifying the condition necessitating the request. All requested information must be provided.
This form must be submitted for each test for which an accommodation is being requested.
Submit this form(s) to the office where you will be testing. Do not attach this form to your applications(s).
Department of Personnel
Department of Personnel
Rm. 196 Howlett Building
17 N. State St., Ste. 1300
Springfield, IL 62756
Chicago, IL 60602
Applicant Information
Name:________________________________________________________ Social Security Number: __________________________
Address: ______________________________________________________ Primary Phone Number: __________________________
City, State, ZIP: _________________________________________________ Secondary Phone Number: ________________________
Reason for Accommodation: _____________________________________________________________________________________
____________________________________________________________________________________________________________
Type of Accommodation Requested: _______________________________________________________________________________
____________________________________________________________________________________________________________
Are you testing for a specific job posting?
☐ YES
☐ NO
Date posting closes: ____________________________________________________________________________________________
Requisition Number for position (as indicated on posting notice): ________________________________________________________
____________________________________________________________________
_____________________________________
Signature of Applicant
Date of Request
OFFICE USE ONLY — DO NOT WRITE BELOW THIS LINE
Request for accommodation: APPROVED ☐
DENIED ☐
Date: ________________________________________________
TELEPHONE ☐
LETTER ☐
Notification of applicant:
Date: ________________________________________________
Alternative Accommodation: _____________________________________________________________________________________
_____________________________________________________
Scheduled Test Date: ___________________________________
Title:________________________________________________________________________________________________________
___________________________________________________________
______________________________________________
Signature of Proctor
Date Administered
Printed by authority of the State of Illinois. Julyr 2013 — 1 — Per D 174.2