Documentation Guidelines

Documentation

Documentation consists of an evaluation by an appropriate professional that relates the current impact of the condition to the requester.

Documentation should include:

  • A diagnostic statement including date of most recent evaluation
  • The current impact of (or limitations imposed by) the condition
  • Treatments, medications, devices or services currently prescribed or used to minimize the impact of the condition
  • The expected duration, stability, or progressing of the condition

Guidelines

The following can be used to guide the professional and student for providing adequate documentation.

  • The evaluator must attach copies or summaries of the specific tests, measures or clerical data used to establish each criteria, and include his/her signature.

Attention Deficit/ Hyperactivity Disorder (ADD/ADHD) Documentation Guidelines

Note: Guidelines are to assist the Student Accessibility and Support in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation for appropriate accommodations. The Student Accessibility and Support reserves the right to deny services or accommodations while receipt of appropriate documentation is pending. A student's Individualized Educational Plan (IEP) alone is not sufficient documentation.

  • Must be completed by a qualified professional (Qualified professionals include: psychiatrists, licensed clinical or educational psychologist, neurologist, qualified developmental pediatricians, and other relevantly trained medical doctors).
  • Should be prepared on letterhead paper from diagnosing professional (Licensure information, address and phone number need to be included)
  • Reasonably current: In most cases, this means within the past three years. To support the need for reasonable and appropriate accommodation for ADHD, the student requesting services must provide documentation verifying the condition and describing its current functional impact.
  • Diagnosis and Relevant Tests must be Comprehensive
    • DSM-IV Diagnosis - A Clear statement of ADD or ADHD as a DSM-IV diagnosis and a description of supporting present symptoms. The diagnostician should use direct language in the diagnosis, avoiding the use of terms such as "suggests", "is indicative of," or attention problems."
    • Psycho-educational or Neuropsychological Assessment - These assessments should include measurements of aptitude, achievement, information processing as well as measures that specifically assess the impact of ADHD. Examples of appropriate testing are: WAIS-III; Woodcock-Johnson-III Achievement Test; Conners AD/HD Rating Scale; Copeland Symptom Checklist for Adult ADD.
  • History: Typically a clinical history will include information from a variety of sources, not necessarily limited to the following:
    • History of ADHD of symptoms by age of seven including evidence of on-going impulsive/hyperactive or inattentive behavior that has significantly impaired functioning over time. Family history for presence of ADHD.
    • Relevant medical and medication history that would rule out other medical conditions that exhibit these symptoms.
    • Relevant psychological and educational history and any relevant interventions.
  • Interpretative Diagnostic Summary:
    • Description of current functional limitations pertaining to an educational setting that are presumably a direct result of problems with attention.
    • Any supplemental assessment or evaluations conducted to establish or rule out other concomitant conditions such as LD (Learning Disability), dyslexia, or psychological impairment.
    • An explanation of how possible alternative diagnosis, such as mood disorders, schizophrenia, substance abuse, anxiety disorders and other possible conditions were explored and ruled out. Assessment of differential diagnoses should be documented, and any co-morbid disabilities identified.
    • Description of medication prescribed and how it affects the student's academic performance.
    • Recommendations for reasonable accommodations in the academic setting.

Deaf and Hard of Hearing Documentation Guidelines

Note: Guidelines are to assist the Student Accessibility and Support in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation for appropriate accommodations. The Student Accessibility and Support reserves the right to deny services or accommodations while receipt of appropriate documentation is pending. A student's Individualized Educational Plan (IEP) alone is not sufficient documentation.

  • Must be completed by a qualified professional. (Qualified professionals include: a certified audiologist or physician with appropriate specialty).
  • Should be prepared on letterhead paper from diagnosing professional (Licensure information, address and phone number need to be included).
  • Reasonably Current: The age of acceptable documentation is dependent upon the condition, the current status of the student, and the student's request for accommodations.
  • A statement regarding the use of hearing aids, their benefits and limitations on hearing (if appropriate).
  • A summary to explain functional impact for an academic setting.
  • Include any information you have on co-existing conditions such as learning disability, testing, and intellectual functioning.

Head Injury/Traumatic Brain Injury Documentation Guidelines

Note: Guidelines are to assist the Student Accessibility and Support in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation for appropriate accommodations. The Student Accessibility and Support reserves the right to deny services or accommodations while receipt of appropriate documentation is pending. A student's Individualized Educational Plan (IEP) alone is not sufficient documentation.

  • Must be completed by a qualified professional (Qualified professionals include physicians, neurologists, licensed clinical, rehabilitation, and school psychologists; neuropsychologists and psychiatrists. Qualified practitioners are those who have been trained in the assessment of head injury or traumatic brain injury).
  • Should be prepared on letterhead paper from diagnosing professional (licensure information, address and phone number need to be included).
  • Reasonably Current: Documentation should be current, preferably within the last three years or from a date following further injury or significant therapy, (the age of acceptable documentation is dependent upon the condition).
Recommended documentation includes
  • A clear statement of the head injury or traumatic brain injury and the probable site of lesion.
  • A statement of the functional impact of limitations of the disorder or disability on learning or other major life activity and the degree to which it impacts the individual in the academic setting for which accommodations are being requested. A neurological educational assessment battery is most helpful in designing appropriate accommodations.
  • A summary of cognitive and achievement measures used (including standardized scores or the percentages used to arrive at conclusion).
  • The impact of medication on the student's ability to meet the demands of the postsecondary environment.
  • Suggestions of reasonable accommodations, which might be appropriate at the postsecondary level, are welcome.

Learning Disability Documentation Guidelines

Note: Guidelines are to assist Student Accessibility and Support in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation for appropriate accommodations. Student Accessibility and Support reserves the right to deny services or accommodations while receipt of appropriate documentation is pending. A student's Individualized Educational Plan (IEP) alone is not sufficient documentation.

  • Must be completed by a qualified professional. (Qualified professionals include: Licensed psychologist, psychiatrist, neuropsychologist, school psychologist, learning disability specialist).
  • Should be prepared on letterhead paper from diagnosing professional (Licensure information and address and phone number need to be included).
  • Reasonably Current: All testing needs to be normed for adults and should be within the last 3-5 years.
  • Testing instruments: Comprehensive psycho-educational evaluations that include but are not limited to the following test for each category:
    Measurements of Aptitude

Measurements of Aptitude

(a complete intellectual assessment with all subtests and standard scores reported)
  • Wechsler Adult Intelligence Scale (WAIS-III)
  • Woodcock Johnson (III) Part 1 (Tests of cognitive ability )
    Academic Achievement

Academic Achievement

(Current levels of functioning in reading, mathematics and written language are required.)
  • Weshler Individual Achievement Test (WIAT)
  • Woodcock Johnson
  • Nelson-Denny Reading test
  • Woodcock Reading Mastery Tests revised
Information Processing

Information Processing

(Specific areas of processing, e.g., short /long term memory; sequential memory; auditory/visual perception/processing; and processing speed)
  • Subtest on WAIS-III
  • Woodcock -Johnson Tests of Cognitive Ability


(Brief instruments such as KBIT and the WRAT do not provide adequate information to support postsecondary accommodations)

Specific items to include in the psycho-educational evaluation

  • A DSM-IV specific diagnostic summary. It should include a clear statement that a learning disability is present with the rationale for this diagnosis. (Note: individual "learning deficits", learning styles", and "learning differences", do not, in and of themselves, constitute a learning disability).
  • A statistical analysis of specific discrepancies if any, identifying how expected performance level was calculated and how actual achievement has been contrasted with expected performance.
  • The conclusion needs to explain the current functional impact or limitations of the disability on learning or other major life activity associated with the college learning environment. The report should include interpretation of assessment with sufficient data to support any particular accommodations recommended.
  • The diagnostician should rule out any alternative diagnoses or explanations of the functional learning limitations.

Physical, Medical and Mobility Impairment Documentation Guidelines

Note: Guidelines are to assist the Student Accessibility and Support in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation for appropriate accommodations. The Student Accessibility and Support reserves the right to deny services or accommodations while receipt of appropriate documentation is pending. A student's Individualized Educational Plan (IEP) alone is not sufficient documentation.

  • Must be completed by a qualified professional (Qualified professionals include: physician, neurologist, or other medical specialist with experience and expertise in the area for which accommodations are being requested. The diagnostician must be an impartial individual who is not a family member of the student). 
  • Should be prepared on letterhead paper from a diagnosing professional (Licensure information, address and phone number need to be included).
Recommended documentation includes
  • A clear statement of the medical diagnosis of the orthopedic/mobility disability or systemic illness.
  • Documentation for eligibility must reflect the current impact the physical disability or systemic illness has on the student's functioning (the age of acceptable documentation is dependent upon the disabling condition, the student's request for accommodations, and the current status of the student). Therefore, disabilities that are sporadic or degenerative may require more frequent documentation.
  • A summary of assessment procedures and evaluation instruments used to make the diagnosis, including evaluation results and standardized scores if applicable.
  • A description of present symptoms that meet the criteria for diagnosis.
  • Medical information relating to the student's needs to include the impact of medication on the student's ability to meet the demands of the postsecondary environment.
  • A statement of the functional impact of limitation of the disability on learning or other major life activity and the degree to which it impacts the individual in the learning context for which accommodations are being requested.
  • Please include any information you have on co-existing conditions such as learning disability, testing, intellectual functioning, and/or academic problems which you feel we should know in order to best design accommodations for this student.

Psychiatric Disabilities Documentation Guidelines

Note: Guidelines are to assist the Student Accessibility and Support in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation for appropriate accommodations. The Student Accessibility and Support reserves the right to deny services or accommodations while receipt of appropriate documentation is pending. A student's Individualized Educational Plan (IEP) alone is not sufficient documentation.

  • Must be completed by a qualified professional. (Qualified professionals include: a licensed psychiatrist, psychologist or professional counselor who has experience diagnosing this condition). 
  • Should be prepared on letterhead paper from the diagnosing professional (Licensure information, when appropriate, and address and phone number need to be included).
  • A specific diagnosis (DSM-IV) and the date of the diagnosis.
  • List of instruments/procedures that were used to diagnose the disorder and all scores to support the diagnosis.
  • Impact of medication on the students learning (side effect of medication).
  • Prognosis for therapeutic interventions.
  • Include any other information relevant to this student's academic needs.
  • A summary or conclusion needs to explain the current functional impact or limitations of the disability on learning or other major life activity associated with the college learning environment. The report should include sufficient data to support any particular accommodations recommended.

Vision Documentation Guidelines

Note: Guidelines are to assist the Student Accessibility and Support in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation for appropriate accommodations. The Student Accessibility and Support reserves the right to deny services or accommodations while receipt of appropriate documentation is pending. A student's Individualized Educational Plan (IEP) alone is not sufficient documentation.

  • Must be completed by a qualified professional. (Qualified professionals include: Ophthalmologists, who are the primary professionals involved in diagnosis and medical treatment of individuals who are blind or experience low vision. Optometrists may provide information regarding the measurement of visual acuity as well as tracking and fusion difficulties. The diagnostician must be an impartial individual who is not a family member of the student). 
  • Should be prepared on letterhead paper from a diagnosing professional (Licensure information, address and phone number need to be included).
Recommended documentation includes
  • A clear statement of vision-related disability with supporting numerical description that reflects the current impact the blindness or vision loss has on the student's functioning (the age of acceptable documentation is dependent upon the disabling condition, the current status of the student and the student's request for accommodations).
  • A summary of assessment procedures and evaluation instruments used to make the diagnosis and a summary of evaluation results including standardized scores.
  • Present symptoms that meet the criteria for diagnosis.
  • Medical information relating to the student's needs, the status of the individual's vision (static or changing) and the degree to which it impacts the individual in the learning context for which accommodations are being requested.
  • Narrative or descriptive text providing both quantitative and qualitative information about the student's abilities that might be helpful in understanding the student's profile including functional limitation, the use of corrective lenses and ongoing visual therapy (if appropriate).