20102011 ACT Extended Time National Testing

Available on All National Test Dates Only in the United States, U.S. Territories, Puerto Rico, and Canada
Test Options
Two test options are available: the ACT (No Writing), which includes four multiple-choice tests, or the ACT Plus Writing, which also includes a 30-minute Writing Test. Check www.actstudent.org to see whether the colleges you are considering require or recommend the ACT Writing Test. 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.

How to Request Extended Time

Students with current professionally diagnosed and documented disabilities may request one of the following: 1. 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. The student must register online for his or her 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, see page 3. 2. Special Testing at school is designed for students whose documented disabilities require accommodations that cannot be provided at a national test center. Examples include: more than time-and-a-half testing time testing over multiple days alternate test formats (Braille, cassettes, audio DVDs, or a reader) use of a scribe or computer for the Writing Test (only for students physically unable to hold a pencil) extended time on the Writing Test only (students with developmental writing disorder, written expression, or dysgraphia) If you need Special Testing, complete a Request for ACT Special Testing instead of registering online or completing this application. See the comparison chart on the back page to determine which form of testing to request.

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 2007) 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 Complete details about ACT policies for documentation of requests for test accommodations are available at: www.act.org/aap/disab/policy.html.

Eligibility Requirements
The ACT 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 2007, 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, Section 504 Plan, or Accommodations Plan must document ALL accommodations requested are provided in school. Submit a copy of your current Individualized Education Program (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 (including high school graduates or homeschooled students), complete documentation is required (see Guidelines for Documentation). 1

Instructions for Completing the Application and Providing Required Documentation

The application may be photocopied or downloaded from www.actstudent.org. To be processed, each application must: be postmarked by the ACT registration deadline for the requested test date, be complete and include all required signatures, be accompanied by all required documentation, and be accompanied by a copy of the admission ticket for the 20102011 test date the student registered for online. If the application is missing any information, signatures, or required documentation, it will not be processed until the missing information is received. This means you may not be approved to test on your preferred test date. If you are approved for extended time, you are not guaranteed a seat at the test center on your admission ticket. You will be assigned to the nearest available center with an extended time seat and will be prompted to print a new admission ticket. Because prior arrangements are necessary, students applying for Extended Time National Testing may not test standby.

H.

I. J.

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.

SIDE 1TO BE COMPLETED BY THE STUDENT/PARENT A. Student Information. Print or type. B. Test Date/Test Option and Test Center Choices. Mark one test date/test option. List your first and second choice test centers. 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, do not complete this application. Follow the instructions on page 3. If ACTs files confirm prior approval, the same accommodations will be authorized. If ACT has not approved extended time previously, your application will not be processed until ACT receives a completed application and required documentation. 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 2007, 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.

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.

Returning the Application by the Deadline

To ensure timely consideration of your request, please apply as early as possible. Applications postmarked after the regular deadline but by the late deadline will be processed for the requested test date, but ONLY if they are complete AND include all required documentation. Applications postmarked after the late deadline will not be processed. The student will still be registered for standard time testing at the test center shown on the admission ticket. Mail your application by the postmark deadline for the requested test date and include all of the following: A copy of the admission ticket for the 20102011 test date the student registered for online. A completed extended time application (both sides). All required supporting documentation. Apply the label on page 1 of this application to the front of your return envelope. (If the label is missing, cut out the copy below and tape it securely to the front of the envelope.)

If you cannot register online with a credit card, call 319/337-1851 for assistance.

EXT TIMEPO BOX 4068 IOWA CITY IA 52243-4068

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.

Response from ACT

If extended time testing cannot be approved based on the information submitted, the student will be notified in writing of ACTs decision to deny extended time. The student will still be registered for standard time testing at the test center shown on the admission ticket. If extended time testing is approved, ACT will re-assign the student to the nearest test center with an extended time seat. There is no guarantee the student will be assigned to the test center printed on the standard time admission ticket. Approval of extended time testing will be noted on the students new admission ticket (top-right corner), and the students name will be listed on an extended time roster at the test center. If an admission ticket is not included with this application, ACT will register the student for the test date marked on the application, but only if the student has already created an ACT Web account. Otherwise, the application cannot be considered. If ACT finds that any of the information provided to support the request for extended time was false, ACT reserves the right to cancel scores.

If You Miss the Test Date for Which You Were Approved for Extended Time
Because of processing costs, the basic 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. To test on a later test date, you can make a Test Date Change prior to the late deadline for that test date, by following the instructions below for your registration method: 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. Return a copy of your Admission Ticket with a note indicating your new test date and your preferred test center for that date. Include a check or money order as payment. You can try to make a Test Date Change on test day only if you are not requesting any accommodations, other than extended time, for which you were not previously approved. If the test center has space, materials, and staff for you to test, you will be allowed to make the change. FEES: If the Test Date Change is made on or before the regular deadline for the new test date, the 20102011 fee is $20.00 plus the Basic Fee for your test option. If the Test Date Change is made after the regular but by the late deadline for the new test date, the fee is $41.00 ($20.00 Test Date Change plus $21.00 Late Fee) plus the Basic Fee for your test option. In either case, your Basic 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 30, 2011, will not be honored.

If You Want to Test Again on a National Test Date With Extended Time
After you test, if you want to re-register for a future national test date and test with the same accommodations, you have the following options: 1. Re-register on the Web. First, create or log in to your ACT Web account using the ACT ID from your Admission Ticket or score report. If you were previously approved for Extended Time National Testing, 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 able to print your admission ticket as soon as we confirm your test center assignment. Payment must be by credit card. Call 319/337-1851 immediately if your admission ticket does not indicate Extended Time in the top-right corner. 2. Re-register 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 $12.00 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 $21.00. Payment must be by credit card. Note: If you are requesting new or different accommodations, you must submit a new extended time application and a copy of the admission ticket for the 20102011 test date you registered for online along with 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.

20102011 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 Social Security Number (optional) Date of Birth Telephone Number (include area code) High School Code

B. TEST DATE/TEST OPTION and TEST CENTER CHOICES. This application is valid only when returned with a copy of your Admission
Ticket postmarked by the deadline for the test date printed on the admission ticket. Forms postmarked after the regular deadline, but by the late deadline, will be processed only if they are complete and include all required documentation. Forms postmarked after the late deadline will not be processed. Test Date/Test Option (Mark only one.) Sept. 11, 2010 Postmark Deadline August 6, 2010 First Choice Test Center Test Center Code: Test Center Name: September 17, 2010

Oct. 23, 2010

Dec. 11, 2010

Detach here before mailing.

Feb. 12, 2011

Apr. 9, 2011

June 11, 2011

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

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

November 5, 2010

_____________________________________
Second Choice Test Center

January 7, 2011 Test Center Code: March 4, 2011 Test Center Name:

_____________________________________
May 6, 2011 City, State/Province, ZIP/Postal Code, Country:

_____________________________________

C. TEST FORMAT REQUESTED (Mark only one.) Braille, cassettes, audio DVDs, and readers are offered ONLY through Special Testing.
If you need any of those formats, complete the Request For ACT Special Testing instead of this application.

Regular Type (10-point) booklet with scannable answer sheet 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.

D. OTHER ACCOMMODATIONS REQUESTED. (Mark only if applicable and enclose supporting documentation.) Students approved for
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 a scribe or computer for the Writing Test are offered ONLY through Special Testing.

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

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

E. STUDENT/PARENT 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 cannot be approved based on the information submitted, I understand I am still registered for standard time testing on the test date printed on my admission 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. If you were not previously approved, leave this item blank and submit an application completed in full with all required documentation.

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:________________________________________________ Students SSN: _______________________________

(optional)

G. DIAGNOSED IMPAIRMENT
1. 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.) 2. When and by whom student was: Date (month/year): Age or grade of student: Person making diagnosis: Name a. FIRST diagnosed* ___________________________________ ___________________________________ b. Re-confirmation (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:

20102011

20092010

20082009

20072008

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.

EXCEPTIONS STATEMENT AND COMPLETE DOCUMENTATION REQUIRED if no IEP, Section 504 Plan, or official accommodations plan is on file OR 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)

E-mail Address

Fax Number (include area code)

Print Officials Name, Title, and School

Telephone Number (include area code)

SIDE 2

KEEP A PHOTOCOPY FOR YOUR FILES.

ACT TEST ACCOMMODATIONS FOR STUDENTS WITH DISABILITIES

20102011 Eligibility to Request Extended Time Which Type of Testing to Request

EXTENDED TIME NATIONAL TESTING

Professionally diagnosed condition. Appropriate documentation on file at school. Extended time used on tests in school due to disability.

SPECIAL TESTING
Professionally diagnosed condition. Appropriate documentation on file at school. Extended time used on tests in school due to disability.

Apply for Extended Time National Testing if the student: Normally uses up to time-and-a-half on tests in school AND Can use a regular type (10-point) or large type (18-point) test booklet, AND Will test at a test center in the U.S., U.S. territories, Puerto Rico, or Canada.

Request Special Testing only if the student: Normally uses more than time-and-a-half on tests (or uses extended time only on writing tests), or Requires testing over multiple days due to the nature of the disability, or Normally uses alternate test formats such as Braille, cassettes, audio DVDs, or a reader; or a scribe or computer for essaysavailable only for students who cannot physically hold a pencil. Needs extended time or alternate formats and will test outside the U.S. or Canada. Timing guidelines based on test format and disability diagnosis. Time for each test individually monitored. May request to test over multiple days (at least one test per day). Requests for accommodations must be warranted by documentation submitted. On written request, supported by documentation, may be authorized for assistance marking responses, magnifying device, reader, Braille device, etc.

Testing Time Authorized

Time-and-a-half: 5 hours total for ACT (No Writing) or 5 hours and 45 minutes total for ACT Plus Writing (includes breaks between tests). Self-paced within total time allowed. Must complete all tests in a single session. Requests for accommodations must be warranted by documentation submitted. On written request, supported by documentation, may be authorized to bring a sign language interpreter for spoken instructions, etc.

Other Accommodations

Forms and Documentation to Submit

Forms may be downloaded from www.act.org/aap/ disab/index.html

20102011 Application for ACT Extended Time National Testing Supporting documentation required: If first diagnosed within last 3 years, complete documentation required. Copy of test accommodations pages from most current IEP, Section 504 Plan, or official accommodations plan. If no current IEP, Section 504, or accommodations plan, include exceptions information and complete documentation specified on application. A copy of your Admission Ticket for the test date for which you are requesting extended time.

20102011 Request for ACT Special Testing Supporting documentation required: If first diagnosed within last 3 years, complete documentation required. Copy of test accommodations pages from most current IEP, Section 504 Plan, or official accommodations plan. If no current IEP, Section 504, or accommodations plan, include exceptions information and complete documentation specified on request. Do not register online or complete a registration folder. Payment of basic fee for test location: U.S., U.S. Territories, Puerto Rico, and Canada: $33 ACT (No Writing); $48 ACT Plus Writing Other locations: (add $26 international surcharge) $59 ACT (No Writing); $74 ACT Plus Writing (not offered in Feb.)
ACT (No Writing) available September 11, 2010, through June 26, 2011; submit request at least 4 weeks before test date (6 weeks preferred); 60 days minimum between repeat Special Testing. ACT Plus Writing administered only during testing windows below; submit request by deadline listed. Postmark Deadline Testing Window Sept. 1126, 2010 Aug. 6, 2010 Oct. 23Nov. 7, 2010 Sept. 17, 2010 Dec. 1126, 2010 Nov. 5, 2010 Feb. 1227, 2011 Jan. 7, 2011 Apr. 924, 2011 Mar. 4, 2011 June 1126, 2011 May 6, 2011 Normally, at school attended by student; if alternate location, explanation required; administered individually or in small groups separated by timing code. Supervisor must meet required qualifications.

Test Dates, Deadlines, and Retest Restriction

Test Date September 11, 2010 October 23, 2010 December 11, 2010 February 12, 2011 April 9, 2011 June 11, 2011

Postmark Deadline August 6, 2010 September 17, 2010 November 5, 2010 January 7, 2011 March 4, 2011 May 6, 2011

May not test both National and Special within 60 days. Refer to www.actstudent.org for test center availability.

Test Location and Supervisor Qualifications Test Information Release Contacting ACT

At scheduled national test centers; administered in small groups (usually no more than 10 in extended time room). Supervisor must meet required qualifications.

Copy of questions and answers available for extra fee after December, April, and June test dates. ACT Registration Extended Time National Testing 301 ACT Drive P.O. Box 4068 Iowa City, IA 52243-4068 Phone: 319/337-1851 (Extended time questions) 319/337-1270 (to order materials) Fax: 319/339-3032

Not available through Special Testing. ACT Special Testing 301 ACT Drive P.O. Box 4028 Iowa City, IA 52243-4028 Phone: 319/337-1332 (voice) 319/337-1701 (TDD) Fax: 319/337-1285

8:30 a.m.5:00 p.m., central time, MF

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