Institutional Verification of Documentation

(Must be printed on official institution letterhead)

How to Complete and Submit the Form

This form may be submitted to fulfill documentation requirements for an examinee requesting select alternative testing arrangements in lieu of submitting documentation to Evaluation Systems.

Authorized institutional representatives should work with examinees to complete the following steps:

  1. Complete each field on the form.
  2. Save an electronic copy of this form.
  3. Print the form on institution letterhead and provide your institutional representative signature.
    Note that ALL pages must be printed on letterhead stock.
  4. Scan it into a document or image file format.
  5. The examinee must then submit the completed document electronically, along with the completed Alternative Testing Arrangements Request Form, via the uploader tool on the Contact Us page of the program website (www.ms.nesinc.com/Contacts.aspx).

For assistance completing this form, please see the Mississippi Foundations of Reading program website for contact information at: www.ms.nesinc.com/Contacts.aspx.

Requirements for Processing Requests

  • This form must be completed in its entirety, signed by an authorized institutional representative from the Office of Disability Services at the examinee's college or university, or signed by an authorized professional at the Department of Vocational Rehabilitation office in the examinee's state of residence, and printed on official institution letterhead.
  • This form will only be accepted as supporting documentation for the alternative testing arrangement(s) listed in section 8 of this form.

Examinee Information

(as indicated by the examinee at the time of registration and as appears on the Alternative Testing Arrangements Request Form completed by the examinee):

  1. Examinee Name

  2. (found in your account at www.ms.nesinc.com)

Authorized Institutional Representative Information

This portion of the form may only be completed by a college/university or vocational rehabilitation representative as described above.

  6. Alternative Testing Arrangements

    Indicate which of the following accommodations are supported by the documentation on file at your institution and provided by your institution for the examinee. If the examinee is requesting an accommodation not listed below, documentation must be submitted directly to Evaluation Systems.

    *All examinees have access to font enlargement up to 200% without prior approval.

Documentation

Please provide the following information contained in the most recent documentation on file for the examinee named in section 1 of this form. Please note that the diagnosing professional cannot be the individual named in section 3.

  1. Diagnosed disability or disabilities:

    If you require more space, you may attach an additional document, printed on institution letterhead, and then submit with this completed form.

  2. Certification

    Please review the below statements. If any of the below statements cannot be certified, please submit documentation directly to Evaluation Systems in lieu of submitting this form.
    By initialing each statement below, I certify that:

  1. I certify that I am the person whose name appears on this form. I have printed this form on official institution letterhead. I have reviewed the "Registering for Alternative Testing Arrangements" section of the current Mississippi Foundations of Reading program website and certify that the documentation supporting the examinee’s request for accommodations referenced on this form meets the criteria described therein and is on file with the institution named on this form. I agree to produce a copy of the documentation referenced on this form for Evaluation Systems upon request as part of program monitoring and review, which may include routine audits. Evaluation Systems reserves the right to suspend the Institutional Verification of Documentation option for an institution found to be in noncompliance with associated requirements as a result of such an audit. I understand that the examinee authorizes the release of this information by submitting a completed Alternative Testing Arrangements Request Form.
 

Print this form on institutional letterhead. You may "save as PDF" first to save it, and then print it on institutional letterhead when you are able to do so.