20132014 ACT Extended Time National Testing

Available on All National Test Dates Only in the United States, US Territories, Puerto Rico, and Canada
Test Option
The ACT (No Writing): four multiple-choice tests in English, mathematics, reading, and science. The ACT Plus Writing: also includes a 30-minute Writing Test. Check with the colleges you are considering to find out whether they require or recommend the ACT Writing Test or check www.actstudent.org for a searchable list of colleges. ACT provides test accommodations in accordance with Title III of the Americans with Disabilities Act (ADA). Schools provide accommodations under different regulations. Thus, having a diagnosis and receiving accommodations in school do not guarantee approval of those accommodations for the ACT.

Guidelines for Documentation

Documentation must be written by the diagnosing professional and must meet ALL of these guidelines: 1. States the specific impairment as diagnosed 2. Is current (no older than September 2010) 3. Describes the presenting problem(s) and developmental history, including relevant educational and medical history 4. Describes the comprehensive assessments (neuropsychological or psychoeducational evaluations), including evaluation dates used to arrive at the diagnosis: For learning disabilities, must provide test results (including subtests), with standard scores and/or percentiles, from a) an aptitude assessment using a complete, valid, and comprehensive battery, b) a complete achievement battery, c) an assessment of information processing, and d) evidence that alternative explanations were ruled out. For ADD/ADHD, must include a) evidence of early impairment, b) evidence of current impairment, including presenting problem and diagnostic interview, c) evidence that alternative explanations were ruled out, d) results from valid, standardized, age-appropriate assessments, and e) number of applicable DSM-IV criteria and how they impair the individual. For visual, hearing, psychological, emotional, or physical disorders, must provide detailed results from complete ocular, audiologic, or other appropriate diagnostic examination. 5. Describes the substantial limitations (e.g., adverse effects on learning, academic achievement, or other major life activities) resulting from the impairment, as supported by the test results 6. Describes specific recommended accommodations and provides a rationale explaining how these specific accommodations address the substantial limitations 7. Establishes the professional credentials of the evaluator, including information about licensure or certification, education, and area of specialization Refer to www.act.org/aap/disab/policy.html for complete details about what documentation to submit in support of requests for test accommodations, including information for homeschooled students or students no longer in high school.

Types of Testing Available

1. Special Testing. If you need any of the following accommodations, DO NOT complete this application or register online. Instead, complete a Request for ACT Special Testing, available at www.actstudent.org/regist/disab/opt3.html. more than time-and-a-half testing time testing over multiple days alternate test formats (Braille, DVDs, or a reader) use of a scribe or computer for the Writing Test (typically for disabilities that prevent students from writing independently) extended time on the Writing Test only (students with developmental writing disorder, written expression disorder, or dysgraphia) 2. Extended Time National Testing (50% more time). Approved students taking the ACT (No Writing) have up to 5 hours to work on the multiple-choice tests at their own pace. Approved students taking the ACT Plus Writing have up to 5 hours and 45 minutes to complete all five tests. The total time allowed for both test options includes breaks between tests. Only regular type (10-point) or large type (18-point) test booklets are available at national test centers. You must register online for your preferred test date in addition to completing this application. To apply for the first time see page 2. If you were previously approved and want to test again with extended time, see page 3.

Eligibility Requirements
The ACT college readiness assessment is offered only in English. Accommodations (including extended time) are not available solely on the basis of limited English proficiency. To request extended time on the ACT, you must meet ALL of the following criteria: 1. Professionally Diagnosed Disability. You must be diagnosed by a qualified professional with credentials appropriate to the diagnosis. Documentation that meets ALL the Guidelines for Documentation on this page must be on file at the school. If diagnosed for the FIRST time before September 2010, reconfirmation is required within the last 3 years. If FIRST diagnosed within the last 3 years, full written documentation must be submitted with the application. 2. Current IEP (Individualized Education Program), Section 504 Plan, or Accommodations Plan must document that ALL accommodations requested are provided in school. Submit a copy of your current IEP, Section 504 Plan, or school accommodations plan. The plan must specify all accommodationsincluding extended timeyou currently receive in school due to the disability. If you do not have a current IEP, Section 504 Plan, or accommodations plan, complete documentation is required. (See Guidelines for Documentation.) This policy also applies if you are homeschooled or no longer attend high school.

Confidentiality of Documentation
All documentation provided to ACT will be kept confidential, will be used solely to determine eligibility for accommodations, and will not become part of your score record. 1

ACT INCEXT TIME (50) PO BOX 4068 IOWA CITY IA 52243-4068

Instructions for Registering

1. Register for an ACT National Test Date by the registration deadline for that test date at www.actstudent.org. 2. Upload a photo according to the on-screen instructions. 3. Print your ticket and send a copy with your application for extended time so we can verify your registration. 4. You will be assigned to test with standard time. 5. If your application for extended time is approved, you will receive an e-mail notification with instructions to print your extended time ticket.

What to Submit
Completed and signed 20132014 Application for Extended Time National Testing (see instructions below). Copy of your ticket. Copy of your accommodations plan (see H and I). Complete documentation, if required (see G, H, and I). Applications received without a registration that includes an acceptable photo, signatures, or required documentation will not be processed until the missing information is supplied. This may prevent you from testing on your preferred test date. Please apply as early as possible. Mail your application by the postmark deadline for the requested test date. Applications postmarked after the regular deadline but received by the late deadline will be processed for the requested test date. Applications received after the late deadline will not be processed. You will receive a letter asking if you want your application considered for the next test date. Applications will NOT be considered for standby testing. You will still be registered at the test center on your ticket if you want to test with standard time. When you complete your application, cut out and tape the label on page 1 to a 9 x12 envelope to ensure ACT receives your materials.

SIDE 2TO BE COMPLETED BY A SCHOOL OFFICIAL G. Diagnosed Impairment. Provide ALL requested information. G-1. This is required and must be specific. For learning disabilities, use the diagnosis as stated in the documentation (DSM-IV diagnosis preferred). G-2. The diagnosing professionals credentials must be appropriate to the diagnosis. G-2a. Specify the date or grade in school of the FIRST diagnosis, usually early in a students education. If the FIRST diagnosis was within the last 3 years, submit complete documentation with the application (see Guidelines for Documentation on page 1). G-2b. If FIRST diagnosed before September 2010, there must be a reconfirmation within the last 3 years by a psychologist, learning disabilities specialist/team, or other qualified professional with direct knowledge of the students disability. An officially endorsed IEP, Section 504 Plan, or official accommodations plan on file within the last three school years can normally serve as reconfirmation if the first diagnosis was made by a qualified professional. H. Documentation Currently on File at School. If YES, check ALL school years during which the student has had an IEP, Section 504 Plan, or official accommodations plan and attach a copy of the test accommodations/services pages from the most recent plan. If the answer is NO or the plan has been in place less than 3 years, follow the instructions for submitting an exceptions statement and complete documentation (see Guidelines for Documentation on page 1). If the student is homeschooled, submit complete documentation. Current Time Accommodations at School. If NO, submit complete documentation and a signed statement on school letterhead. School Officials Signature and Contact Information. Read and sign the statement, and provide your e-mail, fax, and work phone numbers where ACT can reach you if additional information is required. A relative of the student may not sign. The diagnostician or school district liaison for homeschooling must sign for homeschooled students. The diagnostician or college special services office must sign for high school graduates.

I. J.

Instructions for Completing the Application and Providing Required Documentation

SIDE 1TO BE COMPLETED BY THE STUDENT/PARENT A. Student Information. Print or type. B. Test Date, Test Option, and Test Center. Mark one test date and test option. Also list your preferred test center. C. Test Format Requested. Documentation of a visual disability is required to support requests for large type (18-pt. only). Both scannable and large block answer sheets are provided with each large type booklet. D. Other Accommodations Requested. If other accommodations are requested due to the diagnosis, you must submit supporting documentation. E. Student/Parent Signatures. The student must read and sign the statement and authorization to release diagnostic information and full documentation. If the student is younger than 18, his/her parent or legal guardian must also sign. F. Previous ACT Testing with Extended Time. If you were previously approved for Extended Time National Testing, and want to test again with the same accommodations, follow the instructions on page 3.

If you cannot register online with a credit card, call 319.337.1851 for assistance.

Review of Applications by ACT

If there is a question about the disability or accommodations, we will try to contact the school for additional information, provided there is time to do so. ACT may, at its discretion, request additional documentation to support any application. The summary Guidelines for Documentation on page 1 and the detailed information on www.act.org reflect professional standards in the field. ACT reviewers are looking for objective evidence that demonstrates impairment as recognized by the Americans with Disabilities Act (ADA). Please keep in mind that not everyone with a diagnosed condition is disabled by it, and not all disabilities result in a substantial limitation or impairment for which extended time on the ACT is an appropriate accommodation. If the student was first diagnosed recently, but has progressed academically without accommodations, or if the student does not currently receive accommodations in school, or has only recently been identified for an accommodations plan, it is especially important that the documentation provide objective evidence of the substantial limitation resulting from the condition and a rationale for extended time.

When ACT Decides on Your Application

If you are approved for extended time, ACT will reassign you to the nearest test center with an extended time seat available. This may not be the test center shown on your standard time ticket. Approval will be noted by Extended Time in the top-right corner of your new ticket and you will be listed on the extended time roster at the test center. If you registered online, you will receive an e-mail notification of your approval and instructions to print your extended time ticket. If you registered by any other method, you will receive the extended time ticket in the mail. If you are not approved, you will be notified in writing. You will still be registered to test at the test center on the standard time ticket. The letter will be mailed to the address provided in section A of the application. To receive a timely response, supply an active e-mail address when creating your Student Web Account. Decisions will not be given by phone. If you have not received a response by mail or e-mail, contact ACT before the test date so that information can be re-sent if the decision has been made.

If You Want to Test Again on a National Test Date With Extended Time
After you test, if you want to reregister for a future national test date and test with the same accommodations, you have the following options: 1. Reregister on the Web. Log in to or create your student Web account. Click the Yes button when asked if you want to test again with the same accommodations and they will be automatically arranged. You will be prompted to print your ticket as soon as we confirm your test center assignment. Payment must be by credit card. Call 319.337.1851 immediately if your ticket does not show Extended Time in the top-right corner. 2. Reregister by Phone. Call 319.337.1851 (Monday Friday, 8:00 a.m.5:00 p.m., central time). Tell the service representative you want to test again with extended time. An additional $14.00 service fee applies to phone orders. If you call after the regular deadline, but by the late deadline for the new test date, there is an additional late fee of $23.00. Payment must be by credit card. If you are requesting new or different accommodations, you must submit a new extended time application and a copy of the ticket for the 20132014 test date you registered for online along with any required documentation to support the new accommodations. If you previously tested through State Testing with extended time, call 319.337.1851 for instructions before completing this application or registering online.

If You Miss the Test Date for Which You Were Approved for Extended Time
The test fee for the ACT is nonrefundable. If you miss the test date for any reason, you have the following options: 1. Request a Test Date Change. If you want to test on a later test date, follow the instructions below. Test Date Change requests received after the late deadline will not be honored. On the Web. Log in to your ACT Web account, and choose Make Changes to Your Registration for that test date. Payment must be by credit card. By Phone. Call 319.337.1851 (MondayFriday, 8:00 a.m.5:00 p.m., central time). Tell the service representative you want to make a Test Date Change and test with extended time. Payment must be by credit card. By Mail. Send a copy of your extended time ticket with a note requesting your new test date and preferred test center for that date. Include a check or money order as payment. FEES: If the Test Date Change is made on or before the regular deadline for the new test date, the fee is $22.00 plus the test fee. If the Test Date Change is made after the regular but by the late deadline for the new test date, the fee is $45.00 ($22.00 Test Date Change plus $23.00 Late Fee) plus the test fee. In any case, your test fee for your original test date will be promptly refunded. 2. Request a Refund for Optional Services. If you do not test and do not make a Test Date Change, you may request a refund of fees paid for optional services (e.g., the Writing Test, Test Information Release, and 5th or 6th college codes) ordered and paid for before the test date. Go to www.actstudent.org, type in refund request in the search bar at the top of the page, and follow the links for instructions. Requests received after July 31, 2014, will not be honored.

20132014 Application for ACT Extended Time National Testing

Sections A through F must be completed by the student/parent. Please print clearly.
A. STUDENT INFORMATION
Name (Last, First, Middle Initial) Street Address City, State/Province, ZIP/Postal Code, Country Name of High School You Currently Attend ACT ID (from ticket) Date of Birth Telephone Number (include area code) High School Code

B. TEST DATE/TEST OPTION and TEST CENTER CHOICES. This application will be processed only if returned with a copy of your
ticket postmarked by the deadline for the test date on the ticket. Forms postmarked after the regular deadline, but received by the late deadline, will be processed. Forms received after the late deadline will be processed for the next test date. Test Date/Test Option (Mark only one.) Sept. 21, 2013

Oct. 26, 2013

Dec. 14, 2013

Detach here before mailing.

Feb. 8, 2014

Apr. 12, 2014

June 14, 2014

n ACT (No Writing) n ACT Plus Writing n ACT (No Writing) n ACT Plus Writing n ACT (No Writing) n ACT Plus Writing n ACT (No Writing) n ACT Plus Writing n ACT (No Writing) n ACT Plus Writing n ACT (No Writing) n ACT Plus Writing

Postmark Deadline August 23, 2013

Preferred Test Center Test Center Code: Test Center Name:

nnnnnn

September 27, 2013

_____________________________________
City, State/Province, ZIP/Postal Code, Country:

November 8, 2013

_____________________________________

January 10, 2014

March 7, 2014

May 9, 2014

C. TEST FORMAT REQUESTED (Mark only one.) Braille, DVDs, and readers are offered ONLY through Special Testing. If you need any

n Regular Type (10-point) booklet with scannable answer sheet n Large Type (18-point only) booklet with both scannable and large block answer sheets. If you request a large type booklet, you must submit
documentation of a visual disability.

of those formats, complete the Request For ACT Special Testing instead of this application.

D. OTHER ACCOMMODATIONS REQUESTED. (Mark only if applicable and enclose supporting documentation.) Students approved for

n Seating at front of room (only if normally provided at school) n Written copy of spoken instructions n Authorization to bring sign language interpreter for spoken instructions (not test items)

extended time are assigned to an extended time room (normally 10 or fewer examinees). It is your responsibility to request accommodations in addition to extended time. You must enclose supporting documentation. Testing over more than one day or with a scribe or computer for the Writing Test are offered ONLY through Special Testing.

n Wheelchair access; table (not desk) n Mark responses in test booklet n Other __________________________

E. STUDENT/PARENT/LEGAL GUARDIAN SIGNATURES (Form cannot be processed without signatures.) I verify the information on this
form is accurate to the best of my knowledge; I authorize release to ACT of diagnostic information by school officials, physicians, or others having such information. I understand that any documentation provided to ACT will be kept confidential, will be used solely to determine eligibility, and will not become part of my score record. If this application is not approved, I understand I am still registered to test with standard time on the test date at the test center on my ticket. If this application is approved, I understand ACT will send me an e-mail prompting me to print my extended time ticket.

__________________________________________ _______________________________________
Students Signature (Parent/legal guardian must also sign if student is under 18.)

___________________
Date

F. PREVIOUS ACT NATIONAL TESTING WITH EXTENDED TIME: _______________________________________ (month/year)

If you were previously approved for Extended Time National Testing AND are requesting new or different accommodations, list the month and year of that test date above and complete BOTH sides of the application. You must submit documentation to support the new accommodations.

SIDE 1

KEEP A PHOTOCOPY FOR YOUR FILES.

Sections G through J must be completed by a qualified individual (not a relative) who can provide verified documentation of the students diagnosed impairment and current test accommodations at the school due to the diagnosis. This is normally a school official such as a counselor, special education teacher, or principal. (If no longer in school or homeschooled, enclose full documentation and complete sections G.1., G.2., and J.)

Students Name: _______________________________________________ E-mail address: _______________________________

(optional)

G. DIAGNOSED IMPAIRMENT
G1. Specific diagnosis: ________________________________________________________________________________________________ (Requiredmust be more specific than learning disabled, other health impaired, perceptual communications disorder, auditory processing deficits, etc. Provide the specific diagnosis for learning disabilities, e.g., reading, mathematics, or written expression.) G2. When and by whom student was: a. FIRST diagnosed* Date (month/year): Age or grade of student: Person making diagnosis: Name __________________________________ __________________________________ ______________________________________ b. Reconfirmation (within last 3 years). _____________________________________________ _____________________________________________ _____________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

Job title ______________________________________ Qualifications (degrees, ______________________________________ specialization, certification) ______________________________________

*COMPLETE DOCUMENTATION REQUIRED if FIRST diagnosis was within the last 3 years, or for visual, hearing, psychological, emotional, or physical disorders. See Guidelines for Documentation, page 1.

H. DOCUMENTATION CURRENTLY ON FILE AT SCHOOL

Circle either YES or NO; check most current and ALL relevant school years; and attach the required documentation. If plan has been in place less than 3 years, complete documentation is required. ALL schoolsIs an Individualized Education Program (IEP), Section 504 Plan, or official accommodations plan on file for this student that states the need for extended time and any other accommodations requested on Side 1 due to the impairment listed above?

YES

Check ALL relevant school years:

n 20132014

n 20122013

n 20112012

n 20102011

ATTACH a copy of test accommodations/services pages from most current plan (with the students name and effective dates).

NO

See Exceptions Statement and Complete Documentation Required below.

AN EXCEPTIONS STATEMENT AND COMPLETE DOCUMENTATION IS REQUIRED if no IEP, Section 504 Plan, or official accommodations plan is on file OR the plan has been in place less than 3 years: Attach a signed statement on school letterhead detailing the test accommodations currently provided in school due to the diagnosis, the conditions under which they are allowed, and the frequency of current usage. Include a copy of ALL documentation of the students diagnosis on file at the school. (See Guidelines for Documentation on page 1.)

I. CURRENT TIME ACCOMMODATIONS AT SCHOOL

Circle YES or NO. If NO, see Exceptions Statement and Complete Documentation Required below.

YES

NO

Does your school officially permit this student extended time for tests (classroom and standardized) as a result of this diagnosis and supporting documentation?

EXCEPTIONS STATEMENT AND COMPLETE DOCUMENTATION REQUIRED. Attach a signed statement on school letterhead from a qualified professional (on staff at the school or school district) who has reviewed the students file to: 1) state under what circumstances extended time would be permitted for this student in school and the basis for providing that accommodation (include complete documentationsee Guidelines for Documentation on page 1; 2) explain why extended time is not currently provided; 3) explain why you believe extended time should be allowed on the ACT; 4) describe any assistance provided for this student outside of school, if known. Exceptions require additional time for review; please apply as early as possible.

J. SCHOOL OFFICIALS SIGNATURE I affirm the student named on this form attends the school where I work. I verify the information
provided on this form and in the attached IEP, Section 504 Plan, accommodations plan, and supporting documentation is accurate, to the best of my knowledge, and reflects the test accommodations currently provided in school.

School Officials Signature (not a relative of student)

Fax Number (include area code)

Print Officials Name, Title, and School

E-mail Address

Telephone Number (include area code)

KEEP A PHOTOCOPY FOR YOUR FILES.

SIDE 2
2013 by ACT, Inc. All rights reserved.

ACT, Inc.Confidential Restricted when data present.

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