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Documentation

To receive academic accommodations and support services from Disability Services, you must first register with our office by providing current documentation submitted by a licensed or certified diagnostician or medical professional. This documentation must be a comprehensive assessment including recommendations, rationale for accommodations, and recommendations for treatment. Requirements and general guidelines for providing documentation are listed below.

In addition, we recommend that if you have a medical condition, you should contact the Center for Health and Wellness, where nurse practitioners and part-time physicians can help you maintain your health.

General Documentation Requirements Documentation Submission Guidelines Learning Disabilities ADHD Psychiatric Disabilities Deaf and Hearing Impairments Blind and Low Vision Impairments Mobility/Orthopedic Disability and Systemic Disorders Medical Conditions

General Documentation Requirements

Your documentation must:

  • Clearly state the diagnosed disability or disabilities
  • Describe the functional limitations resulting from the disability or disabilities
  • Completed within the last five years for a learning disability, last six months for psychiatric disabilities, or last three years for ADHD and all other disabilities. This requirement does not apply to physical or sensory disabilities of a permanent or unchanging nature.
  • Include complete educational, developmental and medical history relevant to the disability for which testing accommodations are being requested
  • Include a list of all test instruments used in the evaluation report and relevant subtest scores used to document the stated disability. This requirement does not apply to physical or sensory disabilities of a permanent or unchanging nature.
  • Describe the specific accommodations requested
  • Adequately support each of the requested testing accommodations
  • Typed or printed on official letterhead and signed by an evaluator qualified to make the diagnosis (include information about license or certification and area of specialization)

These criteria are adapted from the Educational Testing Service (ETS). Copyright © 2010 by Educational Testing Service. All rights reserved.

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Documentation Submission Guidelines

The Association on Higher Education and Disability (AHEAD) presents the following principles as the foundation for policies and best practices used by post-secondary institutions as they establish disability documentation guidelines and determine accommodations for students with disabilities.

  1. All documentation should be reviewed on an individual, case-by-case basis. This calls for an individualized inquiry, examining the impact of a disability on the individual and within the specific context of the request for accommodations. There is no list of covered disabilities or accepted diagnostic criteria. Institutional documentation policy should be flexible, allowing for the consideration of alternative methods and sources of documentation, as long as the essential goal of adequately describing the current impact of the disability is met.
  2. Determination of a disability doesn’t require the use of any specific language. Service providers should avoid elevating form over substance in documentation guidelines, e.g., the temptation to require specific language, such as “learning disability.” Clinicians’ training or philosophical approaches may result in their use of euphemistic phrases, rather than specific diagnostic labels; this practice should not be automatically interpreted to suggest that a disability does or does not exist.
  3. Presented documentation can be augmented through interview. Service providers are encouraged to contact the evaluator, as necessary, for clarification of any information — such as test results, conclusions and recommendations — contained in documentation. An interview, filtered by the service provider's professional judgment, is extremely valuable in substantiating the existence of a disability, understanding its impacts and identifying appropriate accommodations.
  4. Determination of accommodations is an interactive process. The individual with a disability is an excellent source of information on strategies that maximize access. In the context of documentation and accommodation planning, the individual is a rich, reliable, and valid source of information on the impact of the disability and the effectiveness of accommodations. The individual with a disability may be provided with his or her first choice of accommodation or an alternative, effective accommodation determined by the institution. While objective confirmation (documentation) is legitimate, so are the lived experiences of the individual.
  5. Documentation of a specific disability does not translate directly into specific accommodations. Reasonable accommodations are individually determined and should be based on the functional impact of the condition and its likely interaction with the environment, such as course assignments, program requirements and physical design. As such, accommodation recommendations may vary from individual to individual with the “same” disability diagnosis and from environment to environment for the same individual.
  6. Disability documentation should be treated in a confidential manner and shared only on a need-to-know basis. Disability-related information should be collected and maintained on separate forms and kept in secure files with limited access.
  7. Information on the individual’s disability is only one component of providing access. Many barriers to full participation reside in the environment (physical, curricular, attitudinal, informational) where proactive redesign can favorably impact sustainable access. Service providers are encouraged to work to increase overall accessibility through system change that makes the institution more inclusive and reduces the need for individual accommodation.

These guidelines are adapted from the Association on Higher Education and Disability. Copyright © 2004-2010, AHEAD, All rights reserved.

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Learning Disabilities

The documentation for a learning disability must meet the following criteria:

1. Conducted by a qualified professional: The following professionals would generally be considered qualified to conduct evaluations, provided that they have additional training and experience in evaluating adolescents and adults with learning disabilities:

  • Clinical or educational psychologist
  • School psychologist
  • Neuropsychologists
  • Learning disabilities specialist
  • Medical doctor with demonstrated training and experience in the assessment of learning disabilities in adolescents and adults.

Use of diagnostic terminology indicating a diagnosis of a specific learning disability by someone whose training and experience is not in these fields is not acceptable. It is not appropriate for professionals to evaluate members of their own families or children of close friends. All reports should be on letterhead, typed in English, dated, signed, and otherwise legible.

2. Current: We acknowledge that once a person is diagnosed as having a learning disability (LD) that qualifies for protection under the Americans with Disabilities Act (ADA), the disability is normally viewed as lifelong. Although the learning disability is ongoing, the severity and manifestations of the condition may change over time.

The provision of reasonable accommodations and services is based upon our assessment of the current impact of the individual's disabilities on his or her academic performance, particularly in testing situations. For LD, testing must generally have been completed within the past five years.

3. Comprehensive: To initially establish eligibility for protections under the ADA, documentation of an LD must be comprehensive. It must validate the need for accommodations based upon the student’s current level of functioning and, if relevant, how that level of functioning may impact test-taking. It should include:

  • Summary of a diagnostic/clinical interview
  • Assessment of the major domains of cognitive and academic functioning
  • List of tests administered, including all standard scores
  • Expert interpretation of the results
  • A clear diagnosis and statement of disability
  • Discussion of the functional limitations and academic functioning levels
  • Recommendations

Areas of weakness identified in prior evaluations must be thoroughly explored in the current evaluation.

  • Diagnostic interview
  • Psychometric assessment (aptitude/cognitive ability, academic achievement, areas of cognitive and information processing, and  any other measure deemed appropriate by the evaluator)
  • Specific diagnosis
  • Test scores from standardized instruments must be provided
  • Each accommodation recommended by the evaluator must include a rationale
  • Interpretive summary

These learning disability documentation guidelines are adapted from the Educational Testing Service (ETS). Copyright © 2010 by Educational Testing Service. All rights reserved.

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ADHD

The documentation for attention deficit/hyperactivity disorder (ADHD) must meet the following criteria:

1. Conducted by a qualified professional. The following professionals generally would be considered qualified to evaluate and diagnose ADHD, provided they have comprehensive training in the differential diagnosis of ADHD and direct experience with an adolescent or adult ADHD population:

  • Licensed psychologist
  • Neuropsychologist
  • Psychiatrist
  • Other relevantly trained medical doctor

It may be appropriate to use a clinical team approach consisting of a variety of educational, medical, and counseling professionals with training in the evaluation of ADHD in adolescents and adults. Documentation that relies on diagnostic terminology indicating ADHD by someone whose training and experience are not in these fields is not acceptable. It is not appropriate for professionals to evaluate members of their own families or children of close friends.

2. Current. The provision of reasonable accommodations and services is based upon clear evidence of the current impact of the disability on the student’s academic performance. In most cases, this means that a diagnostic evaluation has been completed within the past three years. Documentation that is more than three years old may be considered if the previous assessment is applicable to the current or anticipated setting.

If documentation is inadequate in scope or content, or does not address the individual's current level of functioning and need for accommodations, reevaluation may be required. In cases where observed changes may have occurred in the individual's performance since the previous assessment, or new treatments may have been prescribed or discontinued since the previous assessment was conducted, it may be necessary to update the evaluation report.

In addition, documentation must include the following components to substantiate a diagnosis:

1. Evidence of early impairment: By definition in the DSM-IV-TR, ADHD is exhibited in childhood or early adolescence (although it may not have been formally diagnosed) and manifests itself in more than one setting. Relevant historical information is essential.

2. Evidence of current impairment:

  • Statement of presenting problem
  • Relevant diagnostic information. The documentation should include a summary of the diagnostic interview conducted by a qualified evaluator. The diagnostic information obtained from the interview should consist of more than self-report, as information from third-party sources is critical in the diagnosis of ADHD.
  • Alternative diagnoses or explanations must be ruled out
  • Relevant testing information must be provided. Neuropsychological or psychoeducational assessment is important in determining the current impact of the disorder on an individual's ability to function in academically related settings. Such assessments might include testing of intellect, achievement, processing speed, fluency, executive functioning, language, memory and learning and attention.
  • Identification of DSM IV-TR criteria
  • Specific diagnosis
  • Interpretation and discussion of diagnostic findings
  • Each accommodation recommended by the evaluator must include a rationale.

These ADHD documentation guidelines are adapted from the Educational Testing Service. Copyright © 1998, 1999 by Educational Testing Service. All rights reserved.

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Psychiatric Disabilities

The documentation for a psychiatric disability must meet the following criteria:

1. Conducted by a qualified professional. Qualified evaluators are defined as those licensed individuals who are qualified to evaluate and diagnose psychiatric disabilities or who may serve as members of the diagnostic team. These individuals or team members may include:

  • Psychologist
  • Neuropsychologist
  • Psychiatrist
  • Neuropsychiatrist
  • Other relevantly trained medical doctor
  • Clinical social worker
  • Licensed counselor
  • Psychiatric nurse practitioner

It is not appropriate for professionals to evaluate members of their own families or children of close friends.

2. Current. Due to the changing nature of psychiatric disabilities, it is essential that a student provide recent and appropriate documentation from a qualified evaluator. Since reasonable accommodations are based upon the current impact of the disability, the documentation must address the individual's current level of functioning and the need for accommodations (e.g., due to observed changes in performance or medication changes since previous assessment).

If the diagnostic report is more than six months old, the student must also submit a letter from a qualified professional that provides an update of the diagnosis, a description of their current level of functioning during the preceding six months, and a rationale for the requested testing accommodations.

3. Comprehensive. The diagnostic report should include the following components:

  • Historical information, diagnostic interview and/or psychological assessment
  • Description of current functional limitations in the academic environment and across other settings
  • Specific diagnosis
  • Relevant information regarding medications
  • Alternative diagnoses or explanations should be ruled out
  • Rationale for requested accommodations must be provided
  • If there is more than one disability, documentation should be comprehensive for each diagnosis

These psychiatric disability documentation guidelines are adapted from the Educational Testing Service (ETS). Copyright © 2001 by Educational Testing Service. All rights reserved.

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Deaf and Hearing Impairments

The documentation for deaf and hearing impairments must meet the following criteria:

1. Conducted by a qualified professional. Physicians, including otorhinolaryngologists and otologists, are qualified to provide diagnosis and treatment of hearing impairments. Audiologists may also provide current audiograms. The diagnostician must be an impartial individual and not a family member of the student.

2. Comprehensive. The documentation must include the following components:

  • Clear statement of deafness or hearing loss, with a current audiogram that reflects the current impact the deafness or hearing 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.
  • Summary of assessment procedures and evaluation instruments used to make the diagnosis and a narrative summary of evaluation results, if appropriate
  • Medical information relating to the student's needs, the status of the individual's hearing (static or changing) and its impact on the demands of the academic program
  • Statement regarding the use of hearing aids (if appropriate)
  • Statement of the functional impacts or limitations of the hearing loss 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.

Further assessment by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated. The student and the coordinator of disability services will collaboratively determine appropriate accommodations.

Source: The Policy Book, LRP Publications, 2000.

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Blind and Low Vision Impairments

The documentation for blind and low vision impairments must meet the following criteria:

1. Conducted by a qualified professional. Ophthalmologists are the primary professionals involved in diagnosis and medical treatment of individuals who are blind or experience low vision. Optometrists provide information regarding the measurement of visual acuity as well as tracking and fusion difficulties. The diagnostician must be an impartial individual and may not be a family member of the student.

2. Comprehensive. The recommended documentation includes:

  • 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
  • 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 its impact on the demands of the academic program
  • 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)
  • A statement of the functional impact or limitations 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

Further assessment by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated. The student and the coordinator of disability services will collaboratively determine appropriate accommodations.

Source: The Policy Book, LRP Publications, 2000

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Mobility/Orthopedic Disability and Systemic Disorders

1. Conducted by a qualified professional. Any mobility/orthopedic disability or systemic disorder is considered to be in the medical domain and requires the expertise of a physician, including a neurologist, physiatrist or other medical specialist with experience and expertise in the area for which accommodations are being requested. The diagnostician must be an impartial individual and may not be a family member of the student.

2. Comprehensive. 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. Disabilities that are sporadic or degenerative may require more frequent documentation
  • Summary of assessment procedures and evaluation instruments used to make the diagnosis, including evaluation results and standardized scores, if applicable
  • 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
  • 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

Further assessment by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated. The student and the coordinator of disability services will collaboratively determine appropriate accommodations.

Source: The Policy Book, LRP Publications, 2000.

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Medical Conditions

The documentation for medical conditions must meet the following criteria:

1. Conducted by a qualified professional. Any medical condition must be determined by the expertise of a physician, including a 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 and may not be a family member of the student.

2. Comprehensive. Recommended documentation includes:

  • Clear statement of the medical diagnosis of the condition
  • Documentation for eligibility must reflect the current impact the condition 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. Disabilities that are sporadic or degenerative may require more frequent documentation.
  • Summary of assessment procedures and evaluation instruments used to make the diagnosis, including evaluation results and standardized scores, if applicable
  • 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
  • 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

Further assessment by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated. The student and the coordinator of disability services will collaboratively determine appropriate accommodations.

Source: The Policy Book, LRP Publications, 2000.

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