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Documentation Guidelines
In
accordance with AHEAD (Association on Higher
Education and Disability) best practices for
documentation, the following guidelines are
provided to ensure the documentation of a
disability reflects an impact upon a major life
activity and supports requests for
accommodations, academic adjustments, and
auxiliary aids.
Psychological/Psychiatric
Disabilities
A
diagnosis by a licensed mental health
professional including psychologists, neuropsychologists, psychiatrists,
neuropsychiatrists, other relevantly trained
medical doctors, clinical social workers,
licensed counselors, and psychiatric nurse
practitioners is required. The diagnostician
must be an impartial individual who is not a
family member of the student.
Appropriate documentation should include the
following:
-
A clear statement of the disability, including the
DSM-IV-TR diagnosis and a summary of present
symptoms (based on the DSM-IV-TR or ICD-10).
-
Current
functional limitations in the academic
environment as well as across other
settings. This may include a history of
presenting symptoms, duration and severity
of the disorder, and relevant historical and
familial data.
-
Medical
information
relating to the needs, including the impact
of medication on ability to meet the demands
of the postsecondary environment. This may
include the current medication regimen and
side effects (if relevant).
-
Relevant
information regarding current treatment, and
a specific request for accommodations with
accompanying rationale. A link must be
established between the requested
accommodations and the functional
limitations of the student in the academic
environment.
-
AD/HD is considered a medical or clinical
diagnosis. The AD/HD form (link)
can be used as a guide to identify
the necessary information.
-
Suggestions
and rationale for reasonable accommodations that might be
appropriate at the post-secondary level are
encouraged.
Adapted from the Guidelines for Documentation of
Psychiatric Disabilities, Educational Testing
Service, July 2001
For the full text of this document, please refer
to
the website for ETS.org
Learning Disabilities
Professionals conducting assessment and
rendering diagnoses of learning disabilities
must be qualified to do so. Trained, certified
and/or licensed school psychologists, neuropsychologists, clinical psychologists,
learning disabilities specialists, and other
professionals with training and experience
relevant to adults and their evaluation are
typically involved in the process of assessment.
The diagnostician must be an impartial
individual who is not a family member of the
student. Appropriate documentation should
include the following:
-
Testing that is current and comprehensive,
including a measure of both aptitude and
academic achievement. Domains to be
addressed should include (but not be limited
to):
Aptitude.The Wechsler Adult Intelligence Scale - III
(WAIS-III) with subtest scores is the preferred
instrument. The Woodcock-Johnson Psychoeducational Battery - III: Tests of
Cognitive Ability
or
the Stanford-Binet Intelligence Scale: Fourth
Edition are acceptable.
Achievement. Current levels of functioning in reading,
mathematics and written language are required.
Acceptable instruments include the
Woodcock-Johnson Psychoeducational Battery -
III: Tests of Achievement; Wechsler Individual
Achievement Test - II (WIAT-II); or specific achievement
tests such as the Test of Written Language -
3 (TOWL-3), Woodcock Reading Mastery Tests -
Revised.
Information Processing.
Specific areas of information processing (e.g.,
short- and long-term memory; sequential memory;
auditory and visual perception/processing;
processing speed) must be assessed. Information
from subtests on the WAIS-III, the
Woodcock-Johnson Tests of Cognitive Ability,
or
the Detroit Tests of Learning Aptitude-Adult (DTLA-A),
as well
as other instruments relevant to
the presenting learning problem(s) may be used
to address these areas.
Current
functional limitations in the academic
environment as well as across other
settings. This may include a history of
presenting symptoms, duration and severity of the disorder, and relevant historical and
familial data.
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 and of themselves,
constitute a learning disability.).
A
narrative summary, including all scores
(standard and percentile), which supports
the diagnosis.
A
statement of strengths and needs that will
impact ability to meet the demands of the
post-secondary environment.
Suggestions and rationale for reasonable
accommodations that might be appropriate at
the post-secondary level are encouraged.
Individual Education Programs (IEPs) and
Section 504 plans are insufficient documentation to
establish the rationale for accommodations.
Adapted From:
University of Connecticut 2007
Medical
Documentation Guidelines
Any physical disability, systemic illness, or
chronic health impairment is
considered to be in the medical domain.
The diagnostician must be an impartial
individual who is not a family member of the
student. Appropriate documentation should
include the following:
-
A
clear
statement of the medical diagnosis from a physician,
neurologist or other medical specialist.
-
Assessment
must reflect the current impact the
physical disability or chronic health impairment has on
the student's functioning.
-
A
description of present symptoms that meet the criteria for
diagnosis.
-
Medical
information relating to the student needs to include the impact of
medication or other treatment on the student's ability to meet
the demands of the postsecondary
environment.
-
Suggestions
and rationale for reasonable accommodations that
might be appropriate at the post-secondary level
are encouraged.
Traumatic Brain Injury
Head injury or traumatic brain injury are
considered medical or clinical diagnoses.
Individuals qualified to render a diagnosis for
these disorders are practitioners who have been
trained in the assessment of head injury or
traumatic brain injury.
The diagnostician must be an impartial
individual who is not a family member of the
student. Appropriate documentation should
include the following:
-
A clear statement
of the head injury or traumatic brain injury and
the probable site of lesion
-
A summary of
cognitive and achievement measures used and
evaluation results including standardized scores
or percentiles used to make the diagnosis
-
A summary of
present residual symptoms that meet the criteria
for diagnosis
-
Medical information
relating to the student’s needs, to include the
impact of medication or other treatment on the student’s ability to
meet the demands of the post-secondary
environment.
-
Suggestions and
rationale for
reasonable accommodations that might be
appropriate at the post-secondary level are
encouraged.
Deaf/Hard of Hearing Documentation Guidelines
To
validate deafness or a hearing loss impairment,
an audiological evaluation and/or audiogram from an
otologist, otolaryngologist or physician is
required.
The diagnostician must be an impartial
individual who is not a family member of the
student. Appropriate documentation should
include the following:
-
Medical
information relating to needs, the status of
the hearing (static or changing),
and its impact on the demands of the academic
program.
-
A
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.
-
A
list of any assistive technology and/or
adaptive equipment currently being used.
-
Suggestions and
rationale for reasonable accommodations that might be appropriate at the post-secondary level are
encouraged.
Blind/ Low Vision
Ophthalmologists are the primary professionals
involved in diagnosis and medical treatment of
individuals who are legally blind or experience
other vision disabilities. Optometrists provide
information regarding the measurement of visual
acuity as well as tracking fusion difficulties
(including, but not limited to eye movement
disorders, inefficiency in using both eyes
together, misalignment of the eyes, lazy
eye, focusing problems, visual sensory disorders
and motor integration).
The diagnostician must be an impartial
individual who is not a family member of the
student. Appropriate documentation should
include the following:
-
A clear statement of vision-related
disability with supporting numerical
description.
-
A summary of assessment procedures and evaluation
instruments used to make the
diagnosis and a summary of evaluation
results, including standardized or
percentile scores.
-
Present symptoms that meet criteria for diagnosis.
-
Medical
information relating to the needs and
the status of the 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
abilities that might be helpful in
understanding the profile, including
the use of corrective lenses and ongoing visual
therapy (if appropriate).
-
Suggestions
and rationale for reasonable accommodations that might be
appropriate at the post-secondary level are
encouraged. These recommendations should be
supported by the diagnosis.
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