Documentation Guidelines

Policy on Learning Disability Documentation

1)   The evaluation must be done by a qualified professional.  Appropriately qualified professionals include: licensed counseling/clinical psychologists, school psychologists, neuropsychologists, and certified or licensed learning disabilities specialists.
A.  This documentation can be prepared only by a person who is not a family member of the student and who is qualified by professional training and practice to diagnose and treat the impairment leading to the disability.  
B.   The evaluator must include credentials, licensure/certification information, address and phone number. 
C.  The evaluation must be typed on professional letterhead, signed, and dated.
2)   Evaluation documentation must be current, usually within the past three years so as to address the current level of functioning and need for accommodations.    Individualized Educational Plans (IEP) and Section 504 plans are valuable sources of information but are not sufficient for documentation of a disability and establishment of accommodations. 
3)    Documentation must be a comprehensive report of a psychoeducational assessment.  All documentation is confidential and is on file only at the Office of Disabilities Services.  In accordance with the guidelines developed by the Association on Higher Education and Disability (AHEAD), the psychoeducational assessment should include:
A.  Relevant educational, developmental, and medical/psychiatric history.
B.   Information from a diagnostic interview and behavioral observations.
C.  Information to substantiate the diagnosis:  Test instruments should be selected in accordance with the professional judgment of the individual performing the assessment.  In general, however, the tests used should be recognized instruments that are valid and that have appropriate norms. All subtests and other test scores must be reported in standard score format.  The assessment must show specific evidence of discrepancies and intra-individual differences that result in substantial functional limitations to learning.  The domains of intellectual aptitude, academic achievement, and cognitive processing should be assessed. 
1.   Aptitude - a complete intellectual assessment is required, with all subtests and standard scores reported. The most current version of the Wechsler Adult Intelligence Scale (WAIS) is the preferred instrument.  Also acceptable are current versions of the Woodcock-Johnson Psycho-Educational Battery: Part 1, Tests of Cognitive Ability or the Stanford-Binet Intelligence Scale.  Abbreviated tests, such as the Kaufman Brief Intelligence Test (KBIT), are not comprehensive and thus, not sufficient. 
2.   Academic Achievement – a comprehensive academic achievement battery with all subtests and standard scores reported for those subtests administered.  The battery should include current levels of academic functioning in relevant areas such as reading (decoding and comprehension), mathematics and oral and written language.  Acceptable instruments include current versions of the Wechsler Individual Achievement Test (WIAT), the Woodcock-Johnson Psycho-Educational Battery: Tests of Achievement, Stanford Test of Academic Skills (STAS), or the Scholastic Abilities Test for Adults (SATA).  Abbreviated tests such as the Wide Range Achievement Test (WRAT) or the Mini-Battery of Achievement (MBA) are not comprehensive measures of achievement and thus, are not sufficient as a sole measure of achievement. 
3.   Information Processing - specific areas of information processing (e.g., short and long term memory, sequential memory, auditory and visual processing, processing, speed, executive functioning, and motor ability).  Use of subtests from the WAIS-3, and /or the cognitive portion of the Woodcock-Johnson Psycho-Educational Battery: Part 1, Tests of Cognitive Ability are acceptable.  Additional testing, such as the Wechsler Memory Scale (WMS-3), designed to assist in corroborating the existence of processing disorders as identified by the WAIS-3 or the WJPEB Part 1, should be used when relevant.
4.   Evidence that the evaluator has ruled out alternative explanations for academic problems, such as poor motivation, poor study skills, psychological problems, etc.
D.  Conclusion: The report should conclude with a clinical summary which describes the functional limitations resulting from the disability. 
E.   The DSM diagnosis and code.  Non-specific statements of the condition (e.g., “relative weaknesses,” “learning disability,” “deficits in”) without a formal diagnosis are not sufficient.
F.   Specific recommendations for accommodations should be based upon the evidence of a substantial limitation to learning supported by specific test results and clinical observations and then directly related to the student’s functional limitations.  These should be specific to an adult educational setting that may be residential. 
4)   The Office of Disabilities Services will make the final determination of eligibility for accommodations and reserves the right to deny services or reasonable accommodations while the receipt of appropriate documentation is pending.  Students must complete the application process, submit disability documentation and bring a current detailed schedule before they can receive accommodations and services.  All documentation is confidential and on file only at the Office of Disabilities Services. 

Policy on Attention Deficit/Hyperactivity Disorder Documentation

AD/HD is a neurological condition that may impair a person’s productivity and rate of learning, though it does not affect specific academic capabilities as is the case with learning disabilities.  AD/HD may constitute a disability if the symptoms are severe enough to significantly affect a major life activity such as learning.  The role of medication is especially important with regard to AD/HD and disability status since medication treatment may reduce the symptoms to the point at which they are no longer disabling.  Thus, students with AD/HD do not automatically qualify for accommodations.  The following documentation guidelines are provided to assure that the documentation of AD/HD demonstrates an impact on a major life activity and supports the request for accommodations, academic adjustments, and/or auxiliary aids. 
1)   The evaluation must be done by a qualified professional.
A.  This documentation can be prepared only by a person who is not a family member of the student and who is qualified by professional training and practice to diagnose and treat the impairment leading to the disability. Appropriately qualified professionals include: licensed counseling/clinical psychologists, neuropsychologists, psychiatrists and other relevantly trained medical doctors.  
B.   The evaluator must include credentials, licensure/certification information, address and phone number. 
C.  The evaluation must be typed on professional letterhead, signed, and dated.
2)   Evaluation documentation must be current, usually within the past three years so as to address the current level of functioning and need for accommodations.  An updated evaluation may be required if observed changes may have occurred in the student’s performance or new medication(s) have been prescribed or discontinued.  The update should then include an assessment of functioning and accommodations, and be related to the previous diagnostic report.  Individualized Educational Plans (IEP) and Section 504 plans are valuable sources of information but are not sufficient for documentation of a disability and establishment of accommodations. 
3)    Documentation must be comprehensive.
A.  Diagnostic interview, including educational, psychosocial, occupational, and medical history.  Demonstrate evidence of ongoing behaviors that significantly impair functioning in two or more settings, having manifested in early childhood, even if not then diagnosed. 
B.  Relevant psychological testing, questionnaires, interviews, or observations used to identify the AD/HD behaviors.  Any tests and scales that are utilized should be recognized instruments that are valid and that have appropriate norms. All subtests and other test scores must be reported in standard score format.  All assessment devices serve as supplements to the diagnostic profile but will not be accepted as substitutes for clinical observations and sound diagnostic judgment.
C.  Relevant medication and other treatment history, including how such treatment affects the student’s current functioning.  Also include whether the medication as prescribed was being taken during the course of the evaluation.  A history of medication usage or a positive response to medication does not confirm a diagnosis, neither does it support or negate the need for accommodations. 
D.  A specific diagnosis with appropriate DSM code.  Rule out alternative diagnoses or explanations, or explain their relative impact upon functioning. 
E.  A statement of whether the symptoms the student is currently experiencing rise to the level of a disability as defined by Section 504 and the ADA and in what ways the disorder substantially limits a major life activity, particularly academic learning.  Clinically significant impairment should be differentiated from common developmental patterns of adolescents and adults (e.g., procrastination, disorganization, distractibility, restlessness, boredom, academic underachievement or failure, low self-esteem, and chronic tardiness or lack of attendance). 
F.  Recommendations for accommodations that are directly related to the student’s current functional limitations, realistic and specific to an adult (possibly residential) educational setting, and can be reasonably provided. 
4)   The Office of Disabilities Services will make the final determination of eligibility for accommodations and reserves the right to deny services or reasonable accommodations while the receipt of appropriate documentation is pending.  Students must complete the application process, submit disability documentation and bring a current detailed schedule before they can receive accommodations and services.  All documentation is confidential and on file only at the Office of Disabilities Services. 

Policy on Blindness and Vision-Related Disability Documentation

Visual disabilities include, but are not limited to: blindness, low level vision, ocular motility dysfunction/eye movement disorders, convergence dysfunction/inefficiency in using both eyes together, strabismus/misalignment of the eyes, amblyopia/lazy eye, accommodative disorders/focusing problems, visual sensory disorders, and motor integration.

1)   The evaluation must be done 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. 
A.  This documentation can be prepared only by a person who is not a family member of the student and who is qualified by professional training and practice to diagnose, treat, and recommend accommodations for the visual disability.
B.   The evaluator must include credentials, licensure/certification information, address and phone number. 
C.  The evaluation must be typed on professional letterhead, signed, and dated.  Handwritten notes on prescription pads or handwritten treatment records will not be accepted. 
2)   Evaluation documentation must be current so as to address the current level of functioning and need for accommodations.  An updated evaluation may be required if observed changes may have occurred in the student’s performance or new treatments have been prescribed or discontinued.  The update should then include an assessment of functioning and accommodations, and be related to the previous diagnostic report.  Individualized Educational Plans (IEP) and Section 504 plans are valuable sources of information but are not sufficient for documentation of a disability and establishment of accommodations. 
3)    Recommended documentation includes: 
A. A clear diagnostic statement of vision-related disability with supporting numerical description (if applicable) that corresponds with the current impact the blindness or visual impairment has upon the student's functioning.  The age of acceptable documentation is dependent upon the status of the visual condition (static or changing), the current functional status of the student and the student's request for accommodations. 
B. A summary of assessment procedures and evaluation instruments used to make the diagnosis and a summary of evaluation results, including standardized scores or ratings, if applicable.
C. Descriptive information specifying the functional impacts or limitations of the vision-related disability upon learning or other major life activity and the degree to which it impacts the individual in the learning environment for which accommodations are being requested. 
 
D. Medical information relating to the student's needs, including the functional impact of assistive devices (e.g. corrective lenses) or treatments upon the student's ability to meet the demands of the postsecondary academic environment.  Also needed is information pertaining to the expected progression or stability of the disability’s impact. 
E. Suggestions of reasonable accommodations that might be appropriate at the postsecondary level are encouraged.  These recommendations should be directly related to the functional limitations of the vision-related disability, as supported by the documentation, and what the student needs to best function in an academic environment.  
4)   The Office of Disabilities Services will make the final determination of eligibility for accommodations and reserves the right to deny services or reasonable accommodations while the receipt of appropriate documentation is pending.  Students must complete the application process, submit disability documentation and bring a current detailed schedule before they can receive accommodations and services.  All documentation is confidential and on file only at the Office of Disabilities Services. 

Policy on Physical and Systemic Disorders Documentation

Physical and systemic disorders include, but are not limited to orthopedic impairments or injuries (recovery from ankle surgery, broken hand, etc.), all chronic health conditions (asthma, diabetes, sickle cell anemia, etc.,), neurological or other condition which substantially limits a student’s participation academically. 
1)   The evaluation must be done by a qualified professional.  Any physical disability or systemic illness is considered to be in the medical domain and requires the expertise of a physician, though other qualified professionals may provide relevant supplemental information. 
A.  This documentation can be prepared only by a person who is not a family member of the student and who is qualified by professional training and practice to diagnose, treat, and recommend accommodations for the medical disability.
B.   The evaluator must include credentials, licensure/certification information, address and phone number. 
C.  The evaluation must be typed on professional letterhead, signed, and dated.  Handwritten notes on prescription pads or handwritten treatment records will not be accepted. 
2)   Evaluation documentation must be current so as to address the current level of functioning and need for accommodations.  An updated evaluation may be required if observed changes may have occurred in the student’s performance or new treatments have been prescribed or discontinued.  The update should then include an assessment of functioning and accommodations, and be related to the previous diagnostic report.  Individualized Educational Plans (IEP) and Section 504 plans are valuable sources of information but are not sufficient for documentation of a disability and establishment of accommodations. 
3)    Recommended documentation includes: 
A. A specific diagnostic statement along with information identifying the disability, date of the current diagnostic evaluation, and the date of the original diagnosis. 
B. A summary of assessment procedures and evaluation instruments used to make the diagnosis, including evaluation results and standardized scores if applicable.
C. Documentation must be recent in order to assess the current impact on academic functioning.  Documentation for eligibility must reflect the current impact the physical disorder 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 functional status of the student.  Therefore, disabilities that are sporadic, progressive, or otherwise change so as to alter necessary accommodations may require more frequent and recent documentation. 
D. Documentation must be comprehensive and establish clear evidence of the condition and a significant impact on academic functioning.  Needed is a description of the current functional impact of the disability upon learning or other major life activity and the degree to which it limits the individual in the learning environment for which accommodations are being requested.  Additionally needed is information pertaining to the expected progression or stability of the disability’s impact over time. 
E. Medical information relating to the student's needs to include the impact of treatments (e.g. medications) and assistive devices upon the student's ability to meet the demands of the postsecondary environment. 
F. Documentation must be relevant to requested accommodations.  Suggestions of reasonable accommodations that might be appropriate at the postsecondary level are encouraged.  These recommendations should be directly related to the functional limitations of the disability. 
4)   The Office of Disabilities Services will make the final determination of eligibility for accommodations and reserves the right to deny services or reasonable accommodations while the receipt of appropriate documentation is pending.  Students must complete the application process, submit disability documentation and bring a current detailed schedule before they can receive accommodations and services.  All documentation is confidential and on file only at the Office of Disabilities Services. 

Policy on Psychological/Psychiatric Disorders Documentation

1)   The evaluation must be done by a qualified professional.  Psychiatric disabilities comprise a range of conditions characterized by emotional, cognitive, and/or behavioral dysfunction.  Appropriately qualified professionals include those licensed as: psychologists, neuropsychologists, psychiatrists, other relevantly trained medical doctors, clinical social workers, counselors (health services providers), and psychiatric nurse practitioners.
A.  This documentation can be prepared only by a person who is not a family member of the student and who is qualified by professional training and practice to diagnose, treat, and recommend accommodations for the visual disability.
B.   The evaluator must include credentials, licensure/certification information, address and phone number. 
C.  The evaluation must be typed on professional letterhead, signed, and dated.  Handwritten notes on prescription pads or handwritten treatment records will not be accepted. 
2)   Evaluation documentation must be current so as to address the current level of functioning and need for accommodations.  An updated evaluation may be required if observed changes may have occurred in the student’s performance or new treatments have been prescribed or discontinued.  The update should then include an assessment of functioning and accommodations, and be related to the previous diagnostic report.  Individualized Educational Plans (IEP) and Section 504 plans are valuable sources of information but are not sufficient for documentation of a disability and establishment of accommodations. 
3)    Recommended documentation includes: 
A. A clear statement of the disability, including the diagnosis according to the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and a summary of present symptoms.  A diagnosis in and of itself does not automatically establish disability or warrant approval of requested accommodations.  The age of acceptable documentation is dependent upon the disabling condition, the current functional status of the student, and the student's request for accommodations. 
B. A summary of assessment procedures and evaluation instruments used to make the diagnosis and a summary of evaluation results, including standardized scores if applicable.
C. Descriptive information stating the functional impacts or limitations of the disability upon learning or other major life activity and the degree to which it impacts the individual in the learning environment for which accommodations are being requested.  This may include a history of significant features of the disorder, duration and severity of the disorder, and relevant historical psychosocial information. 
D. Treatment information relating to the student's needs, including the functional impact of medications or other treatments upon the student's ability to meet the demands of the postsecondary academic environment.  This may include the current medication/treatment regimen and any relevant side effects.  Also needed is information pertaining to the expected progression or stability of the disability’s impact. 
E. Suggestions of reasonable accommodations that might be appropriate at the postsecondary level are encouraged.  These recommendations should be directly related to the functional limitations of the disability, as supported by the documentation, and what the student needs to best function in an academic environment.  
4)   The Office of Disabilities Services will make the final determination of eligibility for accommodations and reserves the right to deny services or reasonable accommodations while the receipt of appropriate documentation is pending.  Students must complete the application process, submit disability documentation and bring a current detailed schedule before they can receive accommodations and services.  All documentation is confidential and on file only at the Office of Disabilities Services.