Documentation Guidelines for Various Disabilities

Current documentation from a qualified medical or psychological professional is required in most cases. Documentation should include diagnosis, prognosis and recommended accommodations.

If you are looking to obtain documentation of a disability, please share the following information with your service provider, as it may assist him or her in providing the information needed to determine your individual accommodations.

The following guidelines for various disabilities are provided to assist the service provider in collaborating with each student to determine appropriate accommodations. Please note that further assessment by an appropriate professional may be required if co-existing disabling conditions are indicated in your evaluation.

General Guidelines for Evaluations

The best quality documentation is provided by a licensed or otherwise properly credentialed professional who has undergone appropriate and comprehensive training, has relevant experience, and has no personal relationship with the individual being evaluated. A good match between the credentials of the individual making the diagnosis and the condition being reported is expected (e.g., an orthopedic limitation might be documented by a physician, but not a licensed psychologist)

Quality documentation includes a description of the diagnostic criteria, evaluation methods, procedures, tests and dates of administration, as well as a clinical narrative, observation, and specific results. Where appropriate to the nature of the disability, having both summary data and specific test scores (with the norming population identified) within the report is recommended. Diagnostic methods that are congruent with the particular disability and current professional practices in the field are recommended. Methods may include formal instruments, medical examinations, structured interview protocols, performance observations and unstructured interviews. If results from informal, non-standardized or less common methods of evaluation are reported, an explanation of their role and significance in the diagnostic process will strengthen their value in providing useful information.

Quality documentation includes a clear diagnostic statement that describes how the condition was diagnosed, provides information on the functional impact, and details the typical progression or prognosis of the condition. While diagnostic codes from the Diagnostic Statistical Manual of the American Psychiatric Association (DSM) or the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization are helpful in providing this information, a full clinical description will also convey the necessary information.

The most comprehensive documentation will include a description of both current and past medications, auxiliary aids, assistive devices, support services, and accommodations, including their effectiveness in ameliorating functional impacts of the disability. A discussion of any significant side effects from current medications or services that may impact physical, perceptual, behavioral or cognitive performance is helpful when included in the report. While accommodations provided in another setting are not binding on the current institution, they may provide insight in making current decisions.

Information on how the disabling condition(s) currently impacts the individual provides useful information for both establishing a disability and identifying possible accommodations. A combination of the results of formal evaluation procedures, clinical narrative, and the individual's self report is the most comprehensive approach to fully documenting impact. The best quality documentation is thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition(s). While relatively recent documentation is recommended in most circumstances, common sense and discretion in accepting older documentation of conditions that are permanent or non-varying is recommended. Likewise, changing conditions and/or changes in how the condition impacts the individual brought on by growth and development may warrant more frequent updates in order to provide an accurate picture. It is important to remember that documentation is not time-bound; the need for recent documentation depends on the facts and circumstances of the individual's condition.

It is helpful when documentation provides information on expected changes in the functional impact of the disability over time and context. Information on the cyclical or episodic nature of the disability and known or suspected environmental triggers to episodes provides opportunities to anticipate and plan for varying functional impacts. If the condition is not stable, information on interventions (including the individual's own strategies) for exacerbations and recommended timelines for re-evaluation are most helpful.

Guidelines for Specific Disabilities

The following section details guidelines for evaluations of specific kinds of disabilities.

Psychological evaluations should include:

A clear statement of the disability, including the DSM-IV diagnosis and a summary of present symptoms.
Documentation for eligibility must reflect the current impact the psychiatric disability 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 accommodation).
A summary of assessment procedures and evaluation instruments used to make the diagnosis and a summary of evaluation results, including standardized or percentile scores.
Medical information related 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 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.

Physical evaluations should include:

A clear statement of the medical diagnosis of the physical 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 evaluation).
A summary of assessment procedures and evaluation instruments used to make the diagnosis and a summary of evaluation results, including results and standardized scores if applicable.
A description of present symptoms which meet the criteria for diagnosis.
Medical information related 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 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.

Any physical disability or systemic illness are considered to be in the medical domain and require the expertise of a physician, including a neurologist, psychiatrist or other medical specialist with experience and expertise in the area for which accommodations are being requested. Examples of this type of impairment include: mobility impairments, multiple sclerosis, cerebral palsy, chemical sensitivities, spinal cord injury,cancer, AIDS, muscular dystrophy, spina bifida. The diagnostician must be an impartial individual who is not a family member of the applicant.

Vision evaluations should include:

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 student's request for accommodations, and the current status of the student).
A summary of assessment procedures and evaluation instruments used to make the diagnosis and a narrative summary of evaluation results including standardized scores.
Present symptoms that meet the criteria for diagnosis.
Medical information relating to the student's needs, and the status of the individual's vision (static or changing), and its impact on the demands of the academic program.
A narrative descriptive text providing both quantitative and qualitative information about the student's abilities which might be helpful in understanding the student's profile including 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.

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. The diagnostician must be an impartial individual who is not a family member of the student.

Learning disability evaluations should include:

Testing that is comprehensive, including a measure of both aptitude and achievement in the areas of reading, mathematics, and written language.
Documentation for eligibility must reflect the current impact the learning disability 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 specific request for accommodations).
A clear statement that a learning disability is present along with the rationale for this diagnosis. (Note: individual "learning deficits", "learning styles," and "learning differences," do not, in or of themselves, constitute a learning disability).
A narrative summary, including all scores, which supports the diagnosis.
A statement of strengths and needs that will impact the student's ability to meet the demands of the postsecondary environment.
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.

Professionals conducting assessment and rendering diagnosis of Specific Learning Disabilities (SLD) must be qualified. A qualified professional needs to hold a degree in a field related to diagnosis of SLD and have at least one year of diagnostic experience with adults and late adolescents. Recommended practitioners may include: certified and/or licensed psychologist, learning disabilities specialists, educational therapists, or diagnosticians. The diagnostician must be an impartial individual who is not a family member of the student.

ADD/ADHD evaluations should include recommended documentation:

Documentation must be current, preferably within the last three years.
Early Impairment/History. Because ADHD is, by definition, first exhibited in childhood, historical and academic information must be gathered and presented by the evaluator.
Second Setting. Likewise, since ADHD is manifested in more than one setting (school, home and social) environments, evidence of impact in settings other than school must be specifically addressed.
Evidence of Current Disabling Condition. Diagnostic assessment must include evidence (not just self-report) of ongoing impulsive, hyperactive or inattentive behavior that has significantly impaired a major life function over time. See Diagnostic Battery below.
Alternative Diagnoses and/or Explanations. Diagnostic assessment should examine the possibility of co-existing diagnoses. This process should explore possible alternative diagnoses including medical and psychiatric disorders as well as educational and cultural factors that impact the individual and may result in behaviors mimicking ADHD.
Diagnostic Battery. Diagnostic assessment must consist of more than a self-report. Assessment must include standardized measures for inattention, hyperactivity and impulsivity as delineated in the DSM-IV. A combination of assessment measures is required. Examples include: rating scales (self and relevant third party), continuous performance tests (e.g., TOVA, IVA), neuropsychological testing (e.g. WAIS-III), and psycho-educational testing (e.g., Woodcock-Johnson III). A continuous performance test is preferred as one of the measures.
Diagnostic Report and Summary. The diagnostic report must be a comprehensive, interpretive summary synthesizing the evaluator's judgment for the diagnosis of ADHD. The report must include:
All quantitative information gained during the testing process, in standard scores and/or percentiles; all relevant developmental, familial, medical, medication, psycho-social, behavioral and academic information.
A specific diagnosis of ADHD based on the DSM-IV diagnostic criteria. In clear, direct language, the report must identify the substantial limitation of a major life function presented by the ADHD.
Specific recommendations for reasonable accommodations. Each recommendation must be based on significant functional limitations and must be supported by the results of the diagnostic assessment.
Mitigating Measures and Treatment. Since reasonable accommodations are based on the current impact of a disability, documentation must address the effects of treatment and/or medication on the individual's present functioning.

Note: Although the more generic term Attention Deficit Disorder (ADD) is frequently used, the official nomenclature used in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), Attention Deficit/Hyperactivity Disorder (ADHD), will be used in this document.

Professionals rendering a diagnosis of ADHD must have comprehensive training in differential diagnosis and direct experience working with adolescents and adults with ADHD. The following professionals are considered qualified to evaluate and diagnose ADHD: clinical psychologists (Ph.D.), neuropsychologists, psychiatrists, and other qualified medical doctors. The diagnostician must be an impartial individual who is not a family member of the student.

Audiological evaluations should include:

A clear statement of Deafness or hearing loss, with an 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 student's request for accommodations, and the current status of the student).
A 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, and the status of the individual's hearing (static or changing), and its impact on the demands of the academic program.
A statement regarding the use of hearing aids (if appropriate).
A statement of the functional impact or limitations of the disability on learning or other major life activities and the degree to which it impacts the individual in the learning context for which accommodations are being requested.

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