"Wastewater System Operator Certification Request for Disability Accommodation in Testing" - Oregon

Wastewater System Operator Certification Request for Disability Accommodation in Testing is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on June 1, 2015;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Oregon Department of Environmental Quality.

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Oregon Department of Environmental Quality
Wastewater System Operator Certification
Request for Disability Accommodation in Testing
APPLICANT INFORMATION
The information requested below, and any documentation regarding your disability and your need for accommodation in
testing, will be considered strictly confidential. The information and documentation you provide will not be shared with any
outside source without your express written permission.
Last Name:
First Name:
Last four digits of SSN:
Mailing Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
e-mail:
ACOMMODATIONS REQUESTED
Testing Site Accessibility
Alternative Format Testing Materials:
Braille
Large Print
Audio Tape
Reader (for visually impaired applicants)
Scribe/Amanuensis (for learning disabled applicants)
Sign Language Interpreter
Extended Testing Time:
Time and a half
Double Time
More than Double Time:
Separate Testing Area
Use of computer or other adaptive equipment. Please describe:
Other:
Some accommodations may require additional documentation or fees.
Comments:
Signature
Date
continued on next page
OpCert ADA Form (6/15)
1
Oregon Department of Environmental Quality
Wastewater System Operator Certification
Request for Disability Accommodation in Testing
APPLICANT INFORMATION
The information requested below, and any documentation regarding your disability and your need for accommodation in
testing, will be considered strictly confidential. The information and documentation you provide will not be shared with any
outside source without your express written permission.
Last Name:
First Name:
Last four digits of SSN:
Mailing Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
e-mail:
ACOMMODATIONS REQUESTED
Testing Site Accessibility
Alternative Format Testing Materials:
Braille
Large Print
Audio Tape
Reader (for visually impaired applicants)
Scribe/Amanuensis (for learning disabled applicants)
Sign Language Interpreter
Extended Testing Time:
Time and a half
Double Time
More than Double Time:
Separate Testing Area
Use of computer or other adaptive equipment. Please describe:
Other:
Some accommodations may require additional documentation or fees.
Comments:
Signature
Date
continued on next page
OpCert ADA Form (6/15)
1
Oregon Department of Environmental Quality
Wastewater System Operator Certification
Document of Disability Related Needs
If you have a learning disability, a psychological disability, or other disability that requires an accommodation in testing,
please have this section completed by an appropriate professional (education professional, doctor, psychologist, or
psychiatrist) to certify that your disabling condition requires the requested test accommodation.
If you have existing documentation for the same or a similar accommodation request, you can submit that documentation
and leave this side of the application blank.
PROFESSIONAL CERTIFICATION
I have known
since
in my capacity as
Test Applicant
Date
Professional Title
I have discussed the nature of this test with the applicant. It is my opinion that because of the applicant’s disability, the
following accommodation(s) should be allowed/provided:
Testing Site Accessibility
Braille
Large Print
Audio Tape
Reader
Scribe/Amanuensis
Sign Language Interpreter
Extended Testing Time:
Time and a half
Double Time
More than Double Time: ___
Separate Testing Area
Use of computer or other adaptive equipment. Please describe:
Other. Please explain:
Name (Print)
Title:
Phone Number:
License Number:
Signature
Date
Operator Certification Program
700 NE Multnomah St, Ste #600
Portland, OR 97232-4100
(503) 229-5161
Fax: (503) 229-6957
Toll free in Oregon: 1-800-452-4011
TTY: 1-800-735-2900
OpCert ADA Form (6/15)
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