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Documentation Guidelines

Conyngham Center • 570-408-4150 (T) • 570-408-4907 (F) • Email

General Documentation Guidelines

Students requesting accommodations and services at Wilkes University are required to submit documentation to determine eligibility in accordance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act.  The following guidelines are provided in the interest of assuring that documentation is complete and accurate. The DSS office reserves the right to determine eligibility and appropriate accommodations/services based on quality, recency, and completeness of the documentation submitted.  All documentation is confidential and will be maintained by the DSS office.

1. Qualified professional must conduct the evaluation.
It is important that the evaluator have comprehensive training and direct experience with the particular disability. The name, title and professional credentials of the evaluator, including information about license or certification, employment, and state/province should be clearly stated in the documentation. All reports should be on letterhead, typed, dated, signed and otherwise legible.

2. Include a diagnostic statement identifying the disability.
The evaluation report must include a clear statement as to how the condition was diagnosed, the functional impact of the disability, and expected progression of the disabling condition.

3. Describe the evaluation methodology.
A comprehensive assessment battery and report typically includes

  1. Evidence of existing impairment
  2. Background information (history of presenting problem(s), any significant developmental, medical, psychosocial information, family history, review of academic history, review of prior evaluation reports, description of current functional limitations pertaining to education, and relevant history of prior treatment, therapy, or accommodations)
  3. Relevant testing (use of multiple measures) and interpretation of results
  4. Specific diagnosis
  5. Rule-out of alternative diagnosis or explanations
  6. Integrated summary including recommendations

4. List current functional limitations.
Discuss how the disabling condition impacts the individual in one or more major life activities in terms of severity, frequency, and pervasiveness.

5. Note expected changes or stability of disability.
Provide information on any expected changes in the functional impact of the disability over time and in response to any environmental triggers.  Information on interventions is also helpful.

6. Discuss current and/or past accommodations, services, and/or medications.
It is important to note any current and/or prior accommodations, support services, auxiliary aids, medications, etc. and their effectiveness on the functional impact of the disability. 

7. Provide recommendations for accommodations, services, and strategies.

  1. Include specific recommendations and rationale for accommodations.
  2. Include a description of the impact of diagnosed disability on specific major life activity.
  3. Recommendations should be supported by specific test results and/or clinical observations.

*Prior history of any particular accommodation does not, in and of itself, warrant its continued provision. An Individualized Education Program (IEP) or a 504 Plan is not sufficient documentation of a disability.

The documentation guidelines discussed above were adapted from the Seven Essential Elements of Quality Disability Documentation in “AHEAD best practices disability documentation in higher education”.

Specific Documentation Guidelines

Learning Disabilities
Documentation must be current for students (within 5 years) requesting accommodations for a learning disability and must include the following:

  • Diagnostic Interview
    Presenting problems, medical, developmental, psychosocial, etc. and a discussion of dual diagnosis where indicated
  • Assessment of Intellectual Functioning
    A complete intellectual assessment with all composite/subtest standard scores reported
  • 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.
  • 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.
  • 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 evaluator should use direct language if he/she is diagnosing and documenting a learning disability, avoiding the use of terms such as "suggests" or "is indicative of" a learning disability.
  • 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 and/or percentiles should be included and are expected to correlate with identified functional limitations and recommendations for accommodation.

Interpretative summary based on a comprehensive assessment should include:

  • Discussion of how patterns in the student's cognitive ability, achievement, and and/or information processing indicate the presence of a learning disability
  • Statement as to if the learning disability substantially impacts learning or other major life activity and the degree to which it impacts the individual’s learning
  • Indication as to why specific accommodations are needed and how the effects of the specific disability may be accommodated
  • Any use of prior accommodations or support services
  • Medical information, as appropriate, should include the impact of medication on the student's ability to meet the demands in a post-secondary environment
  • Rule out possible alternative diagnoses or explanations for the symptoms (e.g., poor education, poor motivation, emotional problems, attentional problems and cultural/language differences)
ADHD

Because symptoms of ADHD can improve in late adolescence and adulthood, a comprehensive evaluation must have been obtained within the last three years. The diagnostic report must specify a specific diagnosis of ADHD based on DSM-IV criteria, and must include the following information in order to establish eligibility for ADA protection:

  1. A clear statement of the existence of an attentional disorder (use DSM-IV codes).
    314.00 Predominately Inattentive Type
    314.01 Predominately Hyperactive-Impulsive Type
    314.01 Combined Type
    314.9 Not Otherwise Specified
  2. A comprehensive written report of:
    • Current presenting symptoms as described by the DSM-IV (including information regarding symptoms that cause impairment in two or more settings (e.g., work, home, school).
    • History (developmental, family, medical, psychosocial, psychological, pharmacological, educational, employment, etc.)
    • Evidence of early impairment (provided from student/parent/teacher of inattention and/or hyperactivity during childhood and presence of symptoms prior to age seven years)
    • Diagnostic test battery and determination of severity (multifaceted evaluation including historical data, observation, and objective diagnostic measures; tests of intelligence, cognition/information processing, and academic achievement (which may not be part of the diagnostic process for ADHD itself), but usually are needed by the university to determine the current impact of the disability on the student's academic performance. This information also is used to determine reasonable accommodations. In addition, these assessments are useful in ruling out a diagnosis of a co-occurring condition(s); scores from a single test or rating scale will not be sufficient for documentation; reports of standardized tests and rating scales administered in a diagnostic evaluation must include quantitative information, including standard scores and percentile ranks)
    • Differential diagnosis (examine the possibility of alternative explanations of symptoms, including medical, psychiatric, educational, and/or cultural factors that impact the individual and may result in behaviors that are similar to ADHD and the possibility of comorbid diagnoses)
    • Professional credentials of the clinician (must have training in differential diagnosis and the full range of psychiatric disorders such as licensed clinical psychologists, neuropsychologists, psychiatrists, and other relevantly trained medical doctors; reports must be typed on official letterhead,, and must include the name, title, professional credentials, address and phone/fax numbers of the evaluator)
  3. A description of the condition's current functional impact on learning or other major life activity relevant to the academic experience
  4. A statement addressing the individual’s requested accommodation(s), including rationale as to why these accommodation(s) are warranted and how they relate to the disorder
  5. A statement regarding how medication (if appropriate) may or may not mitigate the attentional disorder (include dosage, frequency, and any adverse side effects)


Physical/Medical Disability

  • A clear statement of the diagnosis of the medical or physical disability
  • Date of initial identification and date of current evaluation
  • A summary of assessment procedures and evaluation instruments used to make the diagnosis
  • A description of the present symptoms/features, including the severity of the disability and expected duration
  • Information regarding the major life activities and specific academic functions that are affected by the disability in a college setting (e.g., walking, seeing, hearing, performing manual tasks, learning, concentrating, attending class, meeting deadlines, etc.)
  • Medication and treatment information, including side effects that may impact the student’s ability to function in a college setting, and
  • Recommendations regarding reasonable accommodations or services appropriate at the postsecondary level, including a clear rationale and justification for those accommodations.

Psychological Disabilities
The documentation must include a current comprehensive assessment of the individual's condition that includes the following:

  • A clear statement of the disability, including the DSM-IV diagnosis and a description of present symptoms
  • A summary of assessment procedures and evaluation instruments used to make the diagnosis and summary of evaluation results
  • Information regarding the severity of the disability and the specific academic functions that are affected because of the disability across university settings (e.g., work completion, concentrating, class attendance, social interactions, self-care, etc.).
  • Information on medication, including side effects, and/or other treatment issues such as compliance that may impact student’s ability to meet the demands of a university environment 
  • Recommendations for accommodations, including a rationale for the accommodations based on specific features/symptoms of the disability

*If the documentation does not reflect the current array of symptoms/features and level of functioning, the student may be required to submit updated information.


Sources: http://www.towson.edu/dss/studentguide/documentationguidelines.asp#3

 

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