<p>Student Name: ______Grade: ______</p><p>State ID: ______Local ID: ______</p><p>Campus: ______Teacher: ______CTC: ______</p><p>Assessment(s) (circle): TAKS TAKS-Accommodated TAKS-M TELPAS Reading, Gr. 10-12 Subject(s):______</p><p>Accommodation Type: (Attach Sample of Accommodation) □ Large Print(LP) □ Other Methods of Response (R) □ Braille (BR) □ Spelling Assistance (R) □ Magnifying or Low-Vision Devices (P) □ Calculation Devices(R) □ Colored Overlays (P) □ Supplemental Aids -Listed in Appendix D (R) □ Place Markers (P) □ Manipulatives - Listed in Accom. Manual (R) □ Reading Test Aloud to Self (P) □ Blank Graphic Organizer (R) □ Oral/Signed Administration for Math, Science & □ Minimize Distractions to the Student (S) SS (OA) □ Individual Administration (S) □ Reading Aloud Test Questions for TAKS-M □ Small-Group Administration (S) Reading (P) □ Multiple or Frequent Breaks (T) □ Sign/Translate Directions (P) □ Reminders to Stay on Task (T) □ Amplification Devices (P) □ TELPAS Paper Administration □ Manipulating Test Materials (P)</p><p>Why does this student need this accommodation (Objective Evidence?)</p><p>Does this student routinely receive this accommodation in classroom instruction? Yes No Is this student receiving support/services through Special Education or 504? Yes No Is this accommodation documented in the student’s IEP/ IAP paperwork? Yes No Other Please attach any pertinent supporting documentation: (Do not include the IEP) ARD/ 504/ LPAC CAMPUS ACCOMMODATIONS APPROVAL COMMITTEE As a committee we have reviewed the 2010-2011 Accommodation Manual and made the following determination:</p><p>□ Approved □ Denied Date: ______Committee Signatures: Printed Name Signature Role ______Campus Test Coordinator ______Comments: Please retain a copy of this request form and supporting documentation. Please note the district may audit this documentation at any time. Page 1 of 1</p>