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, or 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 Disability Documentation form can be used as a guide to identify the necessary information

Adapted from the Guidelines for Documentation of Psychiatric Disabilities, Educational Testing Service, July 2001

For the full text of this document, please refer to www.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 expertise relevant to adults 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.
  • Individual Education Programs (IEPs) and Section 504 plans are insufficient documentation to establish the rationale for accommodations.

Adapted From: University of Connecticut 2007

Medical Disabilities

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.

Traumatic Brain Injuries

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 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.
  • Information to include the impact of medication or other treatment on the student’s ability to meet the demands of the post-secondary environment.

Deaf/Hard of Hearing

To validate deafness or a hearing 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:

  • A clear statement of deafness/hearing impairment, with an audiogram that reflects the current impact of the deafness/hearing impairment on the student's functioning.
  • 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 impact or limitations of the deafness/hearing impairment on learning or other major life activites and the degree to which it impacts the individual.
  • A list of any assistive technology and/or adaptive equipment currently being used.

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 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.
  • A statement of the functional impact or limitations of the blindness/low vision on learning or other major life activites and the degree to which it impacts the individual.
  • 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).