Documentation Guidelines

1. Be conducted by a qualified evaluator.
   • A practitioner trained in the assessment of ADHD, such as a psychologist, psychiatrist, pediatrician, neuropsychologist, or a combination of such professionals, is recommended.
   • The diagnostician must be an impartial individual with no relationship to the family.
   • Reports must be dated, signed, and include credentials and licensing information of the evaluator.
2. Must be current.
   • ADHD can affect an individual over their lifespan, but the determination of eligibility for disability services is based on the current impact on academic performance.
   • Evaluations should include adult-normed standardized testing and have occurred within the last three (3) years.
3. A diagnostic statement using the DSM-5 must be included.
4. Comprehensive history of presenting problems.
   • Reports must include relevant historical information (medical, developmental, educational, and psychosocial).
   • A description of the impact(s) the disability has had to date on the individual’s learning and other major life activities.
   • A description of any record of prior use of educational support, accommodations, auxiliary aids, and their efficacy.
5. Comprehensive assessment data.
   • Summary of assessment procedures and evaluation instruments used to make the diagnosis.
   • In the relevant areas listed below, using the most recent edition of each standardized assessment instrument and a comparison to the relevant adult norm-referenced group. Include an appendix with all scores obtained during the course of the evaluation, including scaled and percentile scores.
     • Aptitude/general cognitive ability
     • Achievement, with detailed assessment of the relevant area of impact
     • Cognitive and information processing, including processing speed and cognitive fluency
     • Memory
     • Attention and executive functioning o Sensory-perceptual functioning o Motor functioning
     • Psychiatric, personality, and behavioral assessments based on the student’s presentation and history
   • Test data should reflect a substantial limitation to learning for which the student is requesting accommodations.
   • Checklists and/or ADHD rating scales can be a helpful supplement in the diagnostic process, but by themselves are not adequate to establish a diagnosis of ADHD.
6. Reports must include a clinical summary.
   • A demonstration that the evaluator has ruled out alternative explanations for academic problems (as a result of poor education, poor motivation and/or study skills, emotional problems).
   • Observations of behavior during the evaluation that may have helped to form the diagnostic impression.

• • Recommendations for reasonable accommodations, including a rationale for each as to how the accommodation correlates with specific functional limitations determined through the diagnostic interview, observation, and/or testing.

1. A qualified professional must conduct the evaluation.
   • A diagnosis by a psychologist, psychiatrist, or medical doctor is recommended.
   • This diagnostician must be an impartial individual who is not a family member of the student, and the diagnosis must include their license number in the report/letter.
   • Summaries from any clinician(s) such as occupational therapists, speech/language pathologists, developmental/educational specialists, and/or social workers who have worked with the student within the last 3 years are encouraged.
2. Documentation must be current.
   • Reports must reflect adult norms and should be based on evaluations performed within the last three (3) years.
   • All documentation (including any supplements), should describe the current impact of the diagnosed condition(s).
   • Documentation should make recommendations appropriate to a college academic environment with rationales based on the information gathered and current test results.
3. Documentation must be comprehensive.
   • Reports should include a history (medical, developmental, academic, familial), and indicate evidence of early impairment, even if not formally diagnosed in childhood or early adolescence.
   • The history of functional limitations of major life activities resulting from the disorder may include, but not be limited to: communication or language skills; social interaction; restricted, repetitive and/or stereotypical patterns of behavior and activities; sensory functioning and sensitivity to environmental conditions and motor planning.
   • Reports should indicate evidence of current impairment, including the results of a diagnostic interview and a battery of psycho-educational tests designed to identify Autism Spectrum Disorder.
   • All test scores must be included, along with an interpretation of each and a summary. Minimally, testing must include a) assessment of cognitive ability/intellectual functioning, b) measurement of academic achievement, c) instruments that measure various domains of information processing, d) other instruments to help rule in or rule out the diagnosis of Autism Spectrum Disorder.
     • Comprehensive testing, based on adult norms where applicable, may include measures of aptitude, achievement, processing, and social communication. This testing may include the following commonly used evaluation instruments:
       • A comprehension standardized IQ test based on adult norms (including cognitive/achievement scores)
       • A communication assessment specifically addressing the use of language in a social context
       • Autism Diagnostic Observation Scale (ADOS)
       • Autism Diagnostic Interview- Revised (ADI-R)
       • Gilliam Autism Rating Scale (GARS)
       • Gilliam Asperger’s Disorder Scale (GADS)
       • Adult Asperger’s Assessment (AAA)
   • A clear statement of the diagnosis, including the DSM-5 code.

• • Reports must indicate that criteria have been met for any DSM-5 diagnosis. If the evaluation does not clearly indicate the existence of Autism Spectrum Disorder, the examiner must state that fact.
  • Medical information relating to the student’s needs; may include impact of current medication to meet the demands of the post-secondary environment.
  • A statement of the current functional impact or limitation of the disability on learning or other major life activities and how it impacts the individual in the learning environment. Include the degree of the impact as compared to the average person, i.e., mild, moderate or severe.
  • Documentation should address any coexisting disorders or suspected coexisting disorders. Students with coexisting diagnoses of any other disability may need to provide the results of a comprehensive medical/educational/or psychological assessment for that particular disorder.
  • Documentation should include recommendations for accommodations that are directly related to the functional limitations, including a rationale explaining why each recommendation for accommodation is appropriate.

1. Report from an audiologist or otolaryngologist that includes the following:
   • Clear statement of deafness or hearing loss.
   • Current audiogram and interpretation that reflects the degree of hearing loss and current impacts the deafness or hearing loss has on the student’s functioning, specifically within an academic and clinical setting.
   • Student’s history with and managing hearing loss.
   • The type of hearing loss (conductive or sensorineural).
   • Status of the student’s hearing in regards to whether the hearing loss is temporary or permanent, and if it is stable or progressive.
   • Whether the condition is mitigated by hearing aids or medication.
   • Recommendations and rationales for reasonable academic accommodations

1. Be conducted by a qualified evaluator.
   • A professional qualified to render a diagnosis of Head Injury/TBI, such as a physician, neurologist, licensed clinical or rehabilitation psychologist, neuropsychologist, or psychiatrist.
   • The diagnostician must be an impartial individual with no relationship to the family.
   • Reports must be dated, signed, and include credentials and licensing information of the evaluator.
2. Clear statement of the Head Injury/TBI.
3. Must be current.
   • Must reflect current impact the injury has on the student’s functioning.
   • The age of acceptable documentation is dependent upon the disabling condition, the current status of the student, and the student’s request for accommodations.
4. Documentation must be comprehensive.
   • Provides medical information relating to student’s needs, which includes the impact of medication on the student’s ability to meet the demands of the academic program.
   • States the functional impact or limitations of the disability on learning or other major life activities and the degree to which it impacts the individual in the academic and clinical environment for which accommodations are being requested.

• • Describes the present residual symptoms which meet the criteria for the diagnosis.
  • Includes cognitive and achievement measures used and the evaluation results, including standardized scores or percentiles used to make the diagnosis.

5. Recommendations and rationales for reasonable accommodations.

1. Be conducted by a qualified evaluator.
   • A qualified evaluator is an educational, clinical, or neuropsychologist or other relevant professional with training and expertise in learning disability assessment.
   • The diagnostician must be an impartial individual with no relationship to the family.
   • Reports must be dated, signed, and include credentials and licensing information of the evaluator.
2. Must be current.
   • Learning disabilities can affect an individual over their lifespan, but the determination of eligibility for disability services is based on the current impact on academic performance. Evaluations should include adult-normed standardized testing.
3. A diagnostic statement using the DSM-5 must be included.
4. Comprehensive history of presenting problems.
   • Describes the impact the disability has had to date on the individual’s learning and other major life activities.
   • A description of any record of prior use of educational support, accommodations, auxiliary aids, and their efficacy is expected.
5. Comprehensive assessment of learning.
   • In the relevant areas listed below, using the most recent edition of each standardized assessment instrument and a comparison to the relevant adult norm-referenced group. Include an appendix with all scores obtained during the course of the evaluation, including scaled and percentile scores.
     • Aptitude/general cognitive ability
     • Achievement, with detailed assessment of the relevant area of impact
     • Cognitive and information processing, including processing speed and cognitive fluency
     • Memory
     • Attention and executive functioning
     • Sensory-perceptual functioning
     • Motor functioning
     • Psychiatric, personality, and behavioral assessments based on the student’s presentation and history
   • Test data should reflect a substantial limitation to learning for which the student is requesting accommodations.
   • A profile of the student’s strengths and weaknesses must be shown to relate to functional limitations that may necessitate accommodations.
6. Clinical summary.
   • A demonstration that the evaluator has ruled out alternative explanations for academic problems (as a result of poor education, poor motivation and/or study skills, emotional problems, attentional problems, or cultural/language differences).
   • A description of patterns in the student’s cognitive ability, achievement, and information processing that support the diagnosis of a learning disability.
   • Observations of behavior during the evaluation that may have helped to form the diagnostic impression.
   • Recommendations for reasonable accommodations, including a rationale for each as to how the accommodation correlates with specific functional limitations determined through the diagnostic interview, observation, and/or testing.

1. Letter or report from a physician in an appropriate medical specialization that includes:
   • The specific medical condition which causes the disability.
   • History of medical treatment and a description of the current treatment plan.
   • Description of current symptoms of the condition and whether the condition is temporary or permanent, and if it is stable or progressive.
   • Information about current prescribed medications used to treat the disability and possible side effects.
   • A description of the functionally limiting manifestations of the condition for which accommodations are being requested.
   • Recommendations with rationales for reasonable academic accommodations.

1. Report from a psychiatrist, psychologist, or mental health care provider the includes:
   • Clear statement of the condition with the DSM-5 or ICD-10 diagnosis.
   • Description of specific, present symptoms experienced by student which meet the criteria for the diagnosis.
   • A summary of the assessment procedures and evaluation instruments used to make the diagnosis.
   • Information about current prescribed medications used to treat the disability and possible side effects.
   • Description of the functional limitation(s) caused by the disability that would impact the academic and/or clinical setting for which accommodations are being requested.
   • Recommendations with rationales for reasonable accommodations.

1. Report or letter from a speech pathologist or physician that includes the following:
   • The specific disabling condition.
   • Whether the condition is temporary or permanent, and if it is stable or progressive.
   • A description of the functional limitation(s) caused by the disability on student’s performance in an academic and/or clinical setting.
   • If recommendations are being made for reasonable accommodations, rationales should be included.

1. Report or letter from an ophthalmologist or optometrist that includes the following:
   • The specific medical condition that causes the visual impairment and how long the student has experienced the condition.
   • The degree of visual acuity, including with corrective lenses.
   • The extent of the visual fields.
   • Whether the condition if temporary or permanent, and if it is stable or progressive.
   • Whether the condition is mitigated by corrective lenses or medication.
   • A description of the functional limitation(s) caused by the disability.
   • Recommendations for reasonable accommodations, including any visual aids.