Disability Documentation Guidelines

Documentation necessary to substantiate a disability should include:

1. Discussion of any history of early impairment.
2. Evidence of current impairment could be both or one of the following below:
   • Statement of presenting problem: A history of the individual's presenting attentional symptoms should include evidence of ongoing impulsive/hyperactive or inattentive behaviors that significantly impair functioning. 
   • Diagnostic Interview: Information collected should consist of more than a self-report, as information from third-party sources is critical in diagnosis. Sources may include but are not limited to family history, developmental history, medical history, psycho-social history, academic history, prior psycho-educational reports, and description of current functional limitations of an educational setting.
3. Any relevant testing information used to supplement the diagnostic profile.
4. Documentation must clearly state a specific diagnosis (DSM) and specify which symptoms are present.
5. Interpretative summary based on a comprehensive evaluative process should include:
   • Demonstration that alternative explanations have been ruled out.
   • Indication of patterns of inattentiveness/impulsivity/hyperactivity across life span and settings used to determine the presence of ADHD.
   • Indication and discussion of the substantial limitation of learning.
   • Rationale as to why specific accommodations are needed. And or evidence that a specific accommodation has been effective in the past.

ADHD is considered a medical or clinical diagnosis. Professionals conducting assessment and rendering diagnosis of ADHD should have appropriate training, such as developmental pediatric psychologists, neurologists, psychiatrists, licensed clinical or educational psychologists, or a combination. 

Documentation necessary to substantiate a disability should include:

1.  A specific diagnosis that conforms to DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) criteria for Autism, Asperger's Syndrome, or Pervasive Developmental Disorder – Not Otherwise Specified.
2. Current functional limitations on major life activities resulting from these disorders include, but are not limited to:
   • Communication or language skills.
   • Social interaction.
   • Restricted, repetitive, stereotyped patterns of behavior and activities.
   • Sensory functioning.
   • Sensitivity to environmental conditions.
   • Motor planning.

Evidence to support the functional limitations this statement may include aptitude testing, standardized tests of language skills, clinical and teacher observations, and standardized scales of symptoms related to autism.

Recommendations for accommodations related to function and their rationale should be stated as any other strategies or services that may benefit the individual in a higher education environment.

Professionals conducting the assessment must have the appropriate training in diagnosing psychiatric conditions. Qualified Professionals include Psychologist, Licensed Clinical Psychologists, Neuropsychologists, Psychiatrists, and other relevantly trained medical doctors.

An IEP or 504 Plan in and of itself may be insufficient documentation but can be included as part of a comprehensive evaluation. A comprehensive assessment battery and report typically include:

1. A diagnostic interview. Interview results should describe presenting problems (medical, developmental, psychosocial) and a discussion of dual diagnosis where indicated.
2. Assessments of one or more the following:
   • Aptitude. A complete intellectual assessment with all sub-tests and standard scores reported (i.e., WAIS-III, Stanford Binet, Woodcock-Johnson test of Cognitive Abilities).
   • Academic Achievement. A comprehensive academic achievement battery should include current levels of functioning in relevant areas such as reading (decoding and comprehension), mathematics, and oral and written language (i.e., Woodcock-Johnson Achievement battery).
   • Information Processing. Specific areas of information processing (e.g., short and long-term memory, sequential memory, auditory and visual perception/processing, processing speed, executive function, and motor ability) should be evaluated and diagnosed as appropriate (i.e., Wechsler Memory Battery).
3. A Specific Diagnosis. It is important to rule out alternative explanations for problems in learning such as emotional, attentional, or motivational problems that may be interfering with learning but do not constitute a learning disability. The diagnostician is encouraged to use direct language in the diagnosis and documentation of a learning disability, avoiding the use of terms such as “suggests” or “is indicative of” a learning disability.
4. Test Scores. The test findings should document the nature and severity of the learning disability and data should logically reflect a substantial limitation to learning. Standard scores or percentiles should be included and are expected to correlate with identified functional limitations and recommendations for accommodation.
5. An interpretative summary which:
   • Rules out alternative explanations for academic problems such as poor education, motivation, emotional problems, attentional problems, and cultural or language differences.
   • Indicates patterns in the student’s cognitive ability, achievement, and information processing reflecting the presence of a learning disability. It must also indicate substantial limitations to learning or other major life activity presented by the disability and the degree of impact in the learning context.
   • Recommends specific accommodations or auxiliary aids. Recommendations for accommodations should:
     • Indicate the specific conditions under which they were used in the past. Medical information, as appropriate, should include the impact of medication on the student’s ability to meet the demands in a post-secondary environment.
     • Include specific recommendations and rationale for accommodations
     • Any recommendations should be supported by specific test results, clinical observations and evidence that a specific accommodation has been effective in the past.

Documentation of a Learning Disability should be no more than three years old if testing instruments normed for children were used in the evaluation. Evaluations using adult-normed testing instruments are considered current for ten years. 

Professionals conducting an assessment and rendering a diagnosis must have comprehensive training and experience with adolescents and adults with learning disabilities. The evaluator can be a licensed psychologist, learning disabilities specialist, educational therapist, or neuropsychologist. 

This includes deafness, visual disabilities, and other health impairments.

Documentation necessary to substantiate a disability should include:

1. A statement on letterhead, by a qualified health professional
2. The statement should include a specific diagnosis, an explanation of specific functional limitations, and any recommendations for support
3. Any summary of assessment procedures and an evaluation of results
4. When warranted, medical information relating to the student should also include the impact of medication on the student's ability to meet the demands in the post-secondary environment

An evaluation must be conducted by a qualified professional with training in diagnosing physical impairments. Qualified professionals include:

1. Mobility or other Health Impairment: physician, neurologist, physiatrist.
2. Vision Impairment: ophthalmologist, optometrist, a neurologist.
3. Hearing Impairment: audiologist; otologist, otorhinolaryngologist.

Documentation necessary to substantiate a disability should include:

1. A summary of assessment procedures, evaluation instruments used to make the diagnosis, and a summary of evaluation results
2. The statement should include a specific diagnosis, the nature of the disability, functional limitations, the status of the student, and any recommendations for support. If specific accommodations are recommended, they must be supported by the assessment with a specific rationale for the accommodations and evidence that the accommodation has been effective in the past.
3. When warranted, medical information relating to the student should also include the impact of medication on the student's ability to meet the demands in the postsecondary environment. 

An evaluation must be conducted by a qualified professional with appropriate training in diagnosing psychological and psychiatric disorders, such as a psychiatrist or clinical psychologist.

Documentation necessary to substantiate a disability should include:

1. Diagnostic interview with a report describing presenting problems, medical, psychosocial, or dual diagnosis where indicated.
2. Assessment of aptitude post-injury with all sub-tests and standard scores reported.
3. Achievement measures since the injury with all sub-tests and standard scores reported.
4. A summary of present residual symptoms, which meet the criteria for diagnosis.
5. Medical information relating to the student's needs should include the impact of medication on the student's ability to meet the demands of the postsecondary environment.
6. A statement of the functional impact or limitation 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 the accommodations are being recommended.
7. Information processing style with test scores and recommendations in the learning environment.
8. Interpretative Summary based on the comprehensive evaluative process. This summary:
   • should demonstrate that the evaluator ruled out alternative explanations for academic problems (such as poor education, motivation, emotional problems, attentional problems, and cultural or language differences.)
   • must indicate patterns in the student's cognitive ability, achievement, and information processing reflecting the presence of a learning disability. It must also indicate substantial limitations to learning or other major life activity presented by the disability and the degree of impact in the learning context.
   • must indicate why specific accommodation or auxiliary aids are needed and specific conditions under which they were used in the past. Medical information, as appropriate, should include the impact of medication on the student's ability to meet the demands in a post-secondary environment.

Recommendations for Accommodations:

1. Include specific recommendations and rationale for accommodations.
2. Include a description of the impact of the diagnosed TBI on specific major life activities.
3. Recommendations should be supported by specific test results and clinical observations that the accommodation has been effective.

An evaluation must be conducted by a qualified professional who has comprehensive training and experience with adolescents and adults with traumatic brain injury, such as a licensed psychologist, neuropsychologist, or rehabilitation specialist in brain injury.