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:

Physical evaluations should include:

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:

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:

Professionals conducting assessment and rendering diagnoses 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 includes:

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:

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.