- Overview: The Eight PAAI Content Areas
- Domain 1: Basic Science (30%)
- Domains 2-4: Immunodeficiency, GI, and Autoimmunity
- Domains 5-7: Pulmonary, Hypersensitivity, and Upper Respiratory Disease
- Domain 8: Skin Disorders
- How the Domains Map to Exam Format
- Registration, Fees, and Eligibility Mechanics
- Building a Domain-Weighted Study Timeline
- Frequently Asked Questions
- Basic science carries 30% of the initial PAAI exam - nearly a third of all 250 questions.
- The exam has four 90-minute sections of 63, 62, 63, and 62 questions, totaling 250 MCQs.
- Passing requires a scaled score of 500 on a 200-800 scale, not a fixed percent-correct cutoff.
- Autoimmunity and other immunological disorders is the lightest domain at just 3% of the blueprint.
Overview: The Eight PAAI Content Areas
The American Osteopathic Conjoint Examination Committee on Pediatric and Adult Allergy and Immunology - the body administering the PAAI examination program under the American Osteopathic Association - organizes the initial certification exam around eight content areas that together account for 100% of scored material. Unlike a generic exam blueprint, these domains are not evenly distributed. One domain alone (basic science) makes up nearly a third of the test, while others occupy single-digit percentages. Understanding this uneven weighting is the single most important strategic input for anyone planning study time.
If you haven't yet reviewed the full breakdown of exam mechanics, timing, and scoring, the Adult & Pediatric Allergy & Immunology Study Guide 2026 is a useful companion to this domain-by-domain walkthrough.
Domain 1: Basic Science (30%)
Basic science is, by a wide margin, the dominant content area on the initial PAAI exam. At 30% of the blueprint, it likely spans roughly 75 of the 250 scored questions - more than any two clinical domains combined. Candidates should expect this domain to test foundational immunology and allergy mechanisms rather than bedside management.
Basic Science
Expect questions rooted in mechanism, pathway, and laboratory correlation rather than pure clinical decision-making.
- Innate and adaptive immune system components and signaling
- Immunoglobulin structure, function, and class-switching
- Complement pathways and cytokine networks
- Mechanisms underlying hypersensitivity classification
- Immunologic laboratory assays and interpretation of values
Because the remote-proctored PARADIGM platform provides electronic lab values, a calculator, and a scratchpad during testing, basic science questions often expect candidates to interpret provided data rather than memorize normal ranges outright. Still, understanding what a given lab value implies mechanistically is essential - the tool only helps if you already know what you're looking for.
Domains 2-4: Immunodeficiency, GI, and Autoimmunity
Three domains sit in the small-to-moderate weight range and together account for 23% of the exam: Primary and Secondary Immunodeficiencies (10%), GI Disorders (10%), and Autoimmunity and Other Immunological Disorders (3%).
Primary and Secondary Immunodeficiencies (10%)
Covers recognition and classification of congenital and acquired immune deficits.
- Antibody deficiency syndromes and combined immunodeficiencies
- Phagocytic and complement deficiencies
- Secondary immunodeficiency from disease or treatment exposure
- Diagnostic workup sequencing for suspected immunodeficiency
GI Disorders (10%)
Focuses on the intersection of gastrointestinal disease and immune/allergic mechanisms.
- Eosinophilic GI disorders
- Food protein-induced conditions
- Immune-mediated GI manifestations relevant to allergy/immunology practice
Autoimmunity and Other Immunological Disorders (3%)
The smallest domain on the blueprint - a handful of questions, but not one to skip entirely.
- Core autoimmune disease recognition relevant to allergy/immunology consultation
- Overlap presentations with immunodeficiency or hypersensitivity domains
Because Autoimmunity sits at only 3%, over-investing study time here at the expense of Basic Science or the organ-system domains is a common inefficiency. Candidates weighing how to allocate limited prep time across all eight areas often find it helpful to compare this blueprint against the difficulty factors discussed in How Hard Is the Adult & Pediatric Allergy & Immunology Exam?.
Domains 5-7: Pulmonary, Hypersensitivity, and Upper Respiratory Disease
These three domains form the clinical core of allergy/immunology subspecialty practice and together represent 37% of the exam - the largest combined block after Basic Science alone.
Pulmonary Diseases (13%)
- Asthma phenotyping, severity classification, and stepwise management
- Obstructive versus restrictive disease differentiation
- Pulmonary manifestations of systemic immunologic disease
Hypersensitivity Reactions and Mast Cell Disorders (11%)
- Type I-IV hypersensitivity classification and clinical correlation
- Drug allergy evaluation and desensitization principles
- Mastocytosis and mast cell activation syndrome recognition
- Anaphylaxis management pathways
Allergic and Non-Allergic Upper Respiratory Tract Diseases (13%)
- Allergic and non-allergic rhinitis differentiation
- Chronic rhinosinusitis with and without nasal polyps
- Immunotherapy indications for upper airway disease
Key Takeaway
Pulmonary, hypersensitivity/mast cell, and upper respiratory domains combined nearly match Basic Science alone - treat them as a single high-priority clinical block during review.
Domain 8: Skin Disorders
Skin Disorders closes out the blueprint at 10%, on par with the immunodeficiency and GI domains. Expect coverage of atopic dermatitis, urticaria and angioedema, contact dermatitis, and cutaneous manifestations tied to underlying immunologic or hypersensitivity disease - connecting this domain conceptually back to both Basic Science and the hypersensitivity domain above.
Skin Disorders (10%)
- Atopic dermatitis staging and management
- Acute and chronic urticaria/angioedema workup
- Contact dermatitis patterns and allergen testing
- Cutaneous signs of systemic immunologic disease
How the Domains Map to Exam Format
The initial PAAI examination delivers 250 multiple-choice questions across four 90-minute sections containing 63, 62, 63, and 62 questions respectively. Scheduled breaks of 10, 30, and 10 minutes bring the total appointment to six hours of answering time plus 50 minutes of breaks - a 6-hour-50-minute testing day. Delivery is remote-proctored through MonitorEDU on the PARADIGM examination platform, so candidates need a suitable computer, a smartphone camera, valid identification, and a private test space; electronic lab values, a calculator, and a scratchpad are provided within the platform itself.
Because the eight domains aren't tied to specific sections - questions from any content area can appear in any of the four 90-minute blocks - pacing strategy matters more than trying to predict which section will cover which domain. With roughly 250 questions spread across ~6 hours of answering time, candidates average under 1.5 minutes per question, which rewards fast recognition of high-weight domains like Basic Science over lingering on low-weight items like Autoimmunity.
| Exam Section | Questions | Time |
|---|---|---|
| Section 1 | 63 | 90 minutes |
| Section 2 | 62 | 90 minutes |
| Section 3 | 63 | 90 minutes |
| Section 4 | 62 | 90 minutes |
Passing is determined by a scaled score of 500 on a 200-800 scale rather than a fixed percentage-correct threshold - meaning raw question count answered correctly doesn't translate directly to pass/fail without scaling. For a deeper explanation of how this scaled scoring works in practice, see the Adult & Pediatric Allergy & Immunology Passing Score 2026 guide.
Registration, Fees, and Eligibility Mechanics
Domain mastery only matters if you're actually eligible to sit for the exam. Eligibility requires AOBIM or AOBP primary certification, an active unrestricted medical license, professional and ethical standing, and verified qualifying allergy/immunology fellowship training. Senior fellows may test after completing at least 80% of required clinical rotations, though certification is finalized only after verified completion of training.
Certification terms also differ depending on when you certify: pre-2025 certificates carry a ten-year term, while the 2025 cohort receives a two-year term. Ongoing maintenance under Osteopathic Continuous Certification (OCC) - a separate longitudinal program from the initial exam covered in this guide - includes 16 untimed, open-resource PAAI questions annually with a 70% annual passing criterion, a $250 annual assessment fee delivered through the AOA Learning Portal starting in 2026, and one quality-improvement activity every ten years, alongside standard licensure and primary-board CME compliance. New diplomates begin OCC after one full calendar year of certification, meaning the 2025 cohort starts in 2027. Note that the OCC blueprint differs from the eight initial-certification domains detailed above.
For the complete cost picture including retake economics and refund mechanics, see Adult & Pediatric Allergy & Immunology Certification Cost 2026, and for a full eligibility checklist, review Adult & Pediatric Allergy & Immunology Requirements 2026.
Building a Domain-Weighted Study Timeline
Rather than dividing study time evenly across eight domains, allocate time proportional to blueprint weight - spend roughly a third of your total review hours on Basic Science, another large block on the three organ-system domains (Pulmonary, Hypersensitivity/Mast Cell, and Upper Respiratory), and comparatively light review on Autoimmunity and Other Immunological Disorders.
Basic Science Deep Dive
- Immune system mechanisms, immunoglobulin biology, complement pathways
- Lab value interpretation practice using platform-style calculator/scratchpad conditions
Organ-System Block
- Pulmonary Diseases, Hypersensitivity/Mast Cell Disorders, Upper Respiratory Tract Diseases
- Timed question sets to build pacing under the ~1.5-minute-per-question constraint
Secondary Domains
- Immunodeficiencies, GI Disorders, Skin Disorders
- Light review of Autoimmunity and Other Immunological Disorders
Full-Length Simulation
- Practice the full four-section, 6-hour-50-minute schedule including break timing
- Review weak domains flagged from simulated sections
You can build and time this kind of full-length simulation using practice questions on the main practice test platform, which lets you rehearse pacing across all eight domains before exam day.
Frequently Asked Questions
Basic Science, at 30% of the blueprint - nearly a third of the 250 scored questions on the exam.
The exam is delivered as four 90-minute sections of 63, 62, 63, and 62 questions; content from any domain can appear in any section rather than being segregated by topic.
No. The OCC blueprint is different from the eight initial-certification content areas covered in this guide, and OCC instead uses 16 untimed, open-resource questions annually with a 70% passing criterion.
No. Passing requires a scaled score of 500 on a 200-800 scale rather than a fixed raw percentage-correct threshold.
See the Adult & Pediatric Allergy & Immunology Requirements 2026 guide, and pair it with practice on the main practice test site once you confirm eligibility.