Documentation Guidelines

April 18th, 2013 by disability

 

General Guidelines for Documentation of a Disability

Documentation is necessary to establish the presence of a disability and the need for accommodations. As relevant to the disability, the documentation should include the following nine elements:

1) A diagnostic statement identifying the disability, date of the most current diagnostic evaluation, and the date of the original diagnosis.

2) A description of the diagnostic tests, methods, and/or criteria used including specific test results (including standardized testing scores) and the examiner’s narrative.

3) A description of the current functional impact of the disability. This may be in the form of an examiner’s narrative, and/or an interview, but must have a rational relationship to diagnostic assessments. For learning disabilities, current documentation is defined using adult norms.

4) A statement indicating treatments, medications, or assistive devices/services currently prescribed or in use, with a description of the mediating effects and potential side effects from such treatments.

5) A description of the expected progression or stability of the impact of the disability over time, particularly the next five years.

6) A history of previous accommodations and their impact.

7) The credentials of the diagnosing professional(s), if not clear from the letterhead or other forms. Please note that diagnosing professionals shall not be family members or others with a close personal relationship with the individual being evaluated.>

8) Documentation prepared for specific non-educational venues (i.e. Social Security Administration, Department of Veterans Affairs, etc.) may not meet the criteria as set forth by SSD.

9) IEP or 504 plans will not be considered sufficient documentation unless accompanied by a current and complete evaluation.

Beyond these nine elements needed for documentation, recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or collateral support services will be considered on a case-by-case basis.

Nationally, most institutions of higher education utilize guidelines developed by the Association of Higher Education and Disability (AHEAD) and the Educational Testing Service (ETS):

ETS Documentation Guidelines
(external link will open a new tab or window)

 

Guidelines for Documentation of a Specific Disability

Psychological

Students with psychological disorders are required to present documentation from psychiatrists or other qualified persons and agencies to make a diagnosis of the disability uses ETS Documentation Guidelines for psychological disabilities.

Students with psychological disabilities, certain medical conditions, and Traumatic Brain Injury will be asked to update their documentation on a yearly basis in order to justify the need to continue their accommodations.

Physical, Medical

Students with physical or medical impairments are required to present documentation from physicians or other qualified persons and agencies to make a diagnosis of the disability.

Learning Disability

Students with a learning disability are required to submit a comprehensive psychological and educational evaluation. Documentation for learning disabilities should include current measures of aptitude (e.g. WAIS-IV), achievement (e.g. current levels of functioning in reading, mathematics, and written language), and information processing. A qualified professional must conduct the evaluation.

Attention Deficit Disorder (AD/HD)

Students with Attention Deficit Disorder (AD/HD) are required to submit comprehensive documentation that substantiates the AD/HD. This documentation should include evidence of early impairment, evidence of current impairment, relevant testing information, and an interpretive summary based on a comprehensive evaluation. A qualified professional must conduct the evaluation.

Qualified professionals may refer to the Educational Testing Services Guidelines for Attention Deficit Disorder and/or the Association of Higher Education and Disability Guidelines for Learning Disabilities for more specific information regarding the documentation of a disability. Copies of each may be obtained from SSD, or by accessing the AHEAD or ETS websites.

Deaf and Hard of Hearing

Students who are Deaf and hard of hearing are required to present documentation of their hearing loss from an audiologist or other qualified professional to make a diagnosis of the disability and provide details of the functional impact of the hearing loss.

In the case of all disabilities, documentation must indicate that the disability substantially limits some major life activity, including learning.