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Specifies retention for one year and secure destruction after.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/exam/","Exam",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/adult-learners-examinee-affidavit-and-accommodations-log-act-workkeys/529483/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/adult-learners-examinee-affidavit-and-accommodations-log-act-workkeys/529483.png","ImageObject",300,407,{"name":42,"@type":43},"Muffet","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-10","2026-10-09",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",20,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"When should the examinee complete the affidavit portion?","Question",{"text":63,"@type":64},"Complete the affidavit when the examinee does not have a formal educational plan indicating the need for accommodations-level supports. The test coordinator assists as needed.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What must the examinee declare regarding past accommodation use?",{"text":68,"@type":64},"The examinee must personally declare that they requested, were previously permitted by a testing authority, and have used the listed accommodations during formal testing situations. The statement must be accurate and truthful.",{"name":70,"@type":61,"acceptedAnswer":71},"How is an accommodation recorded in the accommodations log for paper testing?",{"text":72,"@type":64},"Indicate the examinee’s accommodation by marking the box labeled Admin Code on the answer document using the appropriate accommodation code for each assessment. For each administered assessment, record the test date and the accommodation code exactly as marked, and note any additional accommodations not directly related to the test.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},529483,1791564746,{"code":4,"msg":82,"data":83},"success",[84,88,92,95,100,105,110,115,119,122,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":93,"slug":94},70,"exam",{"id":96,"doc_module":4,"doc_module_name":25,"category_name":97,"show_sort_weight":98,"slug":99},5,"Comic",60,"comic",{"id":101,"doc_module":4,"doc_module_name":25,"category_name":102,"show_sort_weight":103,"slug":104},6,"Technology",50,"technology",{"id":106,"doc_module":4,"doc_module_name":25,"category_name":107,"show_sort_weight":108,"slug":109},7,"Healthcare",40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":55,"slug":118},9,"Religion & Spirituality","religion-spirituality",{"id":55,"doc_module":4,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},"World Cup","world-cup",{"id":123,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":123,"slug":125},10,"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":96,"slug":129},19,"General","general",{"code":4,"msg":82,"data":131},{"doc_id":79,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":33,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":139,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":12,"update_tm":143,"read_time":111,"preview_page_count":4},962090768927,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","ADULT LEARNERS Examinee Affidavit and Accommodations Log  \nPROGRAM: NATIONAL | PRODUCT: WORKKEYS | AUDIENCE: EXAMINEES, TESTING STAFF  \nTest coordinator: For each accommodated assessment, work with the examinee to complete this form as needed. Both the examinee and the test coordinator should sign to indicate the following:  \n• The test coordinator has verified the examinee’s qualification to use accommodations-level supports as indicated.  \n• The accommodation specified has been provided.  \nAffadavit: Complete the affidavit portion when examinees do not have a formal educational plan that indicates the need for accommodations.  \nLog: For each assessment administered with accommodations, complete the log, listing the type of accommodations supports administered.  \nThe form does not need to be returned to ACT. Keep it for your records for one year, then securely destroy.  \n\n| Test Site Name |\n| --- |\n| Examinee Name |\n\nExaminee ID Number Test Date  \nExaminee Affadavit  \nExaminee: Complete this affadavit (personal declaration) section with the assistance of the test coordinator.  \nTest coordinator: In the space below, provide previously used accommodations during a formal testing situation if no formal education plan is available.  \nMy signature at the bottom of this statement means that I declare the following personal statements to be ACCURATE and TRUTHFUL:  \nI have requested, and have been previously permitted by a testing authority to use, and personally have used the accommodation(s) listed on this form during one or more of the following formal testing situations (Check all that apply and give source):  \nPrior testing during school or vocational training experience  \nInstitution Name  \n© 2025 by ACT Education Corp. All rights reserved. Page 1 of 3 FT70002 .CJ19730  \nPrior testing during military service, or service to other government or service organization  \n\n| Organization Name\u003Cbr>Prior testing during work experience |\n| --- |\n| Employer Name\u003Cbr>I understand that I may use only ACT allowable accommodations supports on this test so that the test is able to measure the essential and fundamental skills it is designed to measure, regardless of my prior history of using other accommodations supports.\u003Cbr>I understand that my qualification to use these supports and the validity of my score on this test rests on the truthfulness of my statement that I have experience using the support(s) I am requesting. I also understand that if this statement is found to be inaccurate or untrue that my test score may, as a result, be invalidated and/or canceled. |\n\nExaminee Signature Date  \nAccommodations Log  \n(Use for paper testing only.)  \nInstructions  \nOn the examinee’s answer document, indicate the examinee’s accommodation by marking the box labeled Admin Code with the appropriate accommodation code for each assessment for which the accommodation was provided. These codes can be found in the Gridding Administration Code section of The ACT WorkKeys Administration Manual.  \nFor each assessment administered, give the test date and the code describing the accommodation provided exactly as it was marked on the examinee’s answer document. Also note any accommodations provided not directly related to the test.  \nApplied Math  \n\n| Date Administered |\n| --- |\n| Admin Code\u003Cbr>Evidence of use:\u003Cbr>Official accommodation plan Signed affidavit of prior plan\u003Cbr>Graphic Literacy |\n| Date Administered |\n\nAdmin Code  \nEvidence of use:  \nOfficial accommodation plan Signed affidavit of prior plan  \nWorkplace Documents  \n\n| Date Administered |\n| --- |\n| Admin Code\u003Cbr>Evidence of use:\u003Cbr>Official accommodation plan Signed affidavit of prior plan\u003Cbr>Applied Technology |\n| Date Administered |\n\nAdmin Code  \nEvidence of use:  \nOfficial accommodation plan Signed affidavit of prior plan  \n© 2025 by ACT Education Corp. All rights reserved. Page 2 of 3 FT70002 .CJ19730  \nAccommodations-level supports (describe):  \nThe signatures below signify the following:  \n• The ","cbCaigQNG1iZR9cD","https://ap.wps.com/l/cbCaigQNG1iZR9cD","pdf",216653,"English","# Examinee Affidavit\n## Qualification for accommodations-level supports\n## Prior testing situations and evidence\n# Accommodations Log (Paper testing only)\n## Instructions for marking Admin Code and recording codes\n## Applied Math, Graphic Literacy, Workplace Documents, Applied Technology entries\n# Signatures and retention","[{\"question\":\"When should the examinee complete the affidavit portion?\",\"answer\":\"Complete the affidavit when the examinee does not have a formal educational plan indicating the need for accommodations-level supports. The test coordinator assists as needed.\"},{\"question\":\"What must the examinee declare regarding past accommodation use?\",\"answer\":\"The examinee must personally declare that they requested, were previously permitted by a testing authority, and have used the listed accommodations during formal testing situations. The statement must be accurate and truthful.\"},{\"question\":\"How is an accommodation recorded in the accommodations log for paper testing?\",\"answer\":\"Indicate the examinee’s accommodation by marking the box labeled Admin Code on the answer document using the appropriate accommodation code for each assessment. For each administered assessment, record the test date and the accommodation code exactly as marked, and note any additional accommodations not directly related to the test.\"}]","ADULT LEARNERS Examinee Affidavit and Accommodations Log - ACT WorkKeys | PDF",1791521298]