Documentation Guidelines

DOCUMENTATION GUIDELINES ARE AVAILABLE HERE IN THREE DIFFERENT FORMATS:

  1. Guidelines are available below in HTML so that they may be read by screen readers
  2. Guidelines are available as WORD documents and can be downloaded and printed. 
  3. Guidelines are also available as PDF documents and can be downloaded and printed. 

YOU MUST HAVE ADOBE ACROBAT READER TO OPEN THESE FILES! The latest version of Acrobat Reader is available FREE for Windows XP at: http://www.adobe.com/products/acrobat/readstep2.html
and is available FREE for the MAC at: http://www.adobe.com/support/downloads/product.jsp?product=10&platform=Macintosh


Go to:

Guidelines for Documentation of a Learning Disability 

The term learning disabilities refers to a heterogeneous group of disorders characterized by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities. Adults with a diagnosis of LD must be of at least average intellectual functioning and exhibit a deficit in one or more of the following areas of neuropsychological functioning: auditory processing, visual processing, information processing speed, memory, spoken and written language skills, reading skills, mathematical skills, spatial skills, motor skills, abstract or general reasoning or executive functioning.

Under the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, individuals with learning disabilities are guaranteed certain protections and rights of equal access to programs and services. In the interest of assuring that LD documentation is appropriate to verify eligibility and to support requests for accommodations, academic adjustments and/or auxiliary aids, the following guidelines have been adopted from the Association on Higher Education and Disability (AHEAD) and established for Montclair State University .

Qualifications of the Evaluator

Professionals conducting assessments, rendering diagnoses of learning disabilities, and making recommendations for appropriate accommodations must be qualified to do so. Training and experiencing in working with an adult population is essential. The following professionals would generally be considered qualified to evaluate specific learning disabilities: trained and certified and/or licensed psychologists, educational psychologists, learning disabilities specialists (LDTCs), and other professionals.

Documentation

Testing needs to be comprehensive. It is not acceptable to administer only one test for the purpose of diagnosis. Minimally, the domains addressed must include, but are not limited to, the following:

  1. Aptitude : A complete intellectual assessment with all subtests and standard scores reported. The preferred instrument is the Wechsler Adult Intelligence Scale III.
  2. Achievement : Current levels of functioning in reading, mathematics, and written language are required. A comprehensive academic achievement battery, with all subtests and standard scores reported, is essential. The Woodcock-Johnson Psycho-Educational Battery – Revised: Tests of Achievement is preferred.
  3. Information Processing : Specific areas of information processing (e.g., short- and long-term memory, sequential memory, auditory and visual perception/processing, processing speed) should be assessed. Information from the Woodcock-Johnson: Tests of Cognitive Ability may be used to address these areas.

This is not intended to be an exhaustive list or to restrict assessment in other pertinent and helpful areas, such as vocational interests and aptitudes. A complete WJ-III is also acceptable providing that it covers all of the above domains.

Testing must be current. Because the provision of reasonable accommodations and services is based upon assessment of the current impact of the student’s disabilities on her/his academic performance at the postsecondary level, it is in the student’s best interest to provide recent and appropriate documentation.

Substantiation of the Learning Disability

Documentation should validate the need for services based on an individual’s current level of functioning. A comprehensive assessment battery and the resulting diagnostic report should include a diagnostic interview, assessment of aptitude, academic achievement, information processing, and a diagnosis.

The evaluation must provide clear and specific evidence that a learning disability does or does not exist. Individual “learning styles” and “learning differences,” in and of themselves, do not constitute a learning disability. 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 expected 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.” If the data indicate that a learning disability is not present, the evaluator should state that conclusion in the report.

A well-written diagnostic summary based on a comprehensive evaluation is also a necessary component of the report. The clinical summary should include:

  • A written summary of background information about the student’s educational, medical, and family histories that relate to the learning disability;
  • 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, and cultural or language differences;
  • Indication of how patterns in the student’s cognitive ability, achievement and information processing reflect the presence of a learning disability;
  • Indication of the substantial limitation to learning or other major life activity presented by the learning disability and the degree to which it impacts the individual at the postsecondary level for which the accommodations are being requested;
  • Indication as to why specific accommodations are needed and how the effects of the specific disability are accommodated; and
  • An addendum of scores.

The report should be printed on letterhead, signed and dated. Credentials of the evaluator should be included.

Recommendations for Accommodations

The diagnostic report should include specific recommendations for accommodations, as well as an explanation as to why each accommodation is recommended. A description of any accommodation or auxiliary aid that has been used at the secondary or postsecondary level should be discussed. If no accommodations have been previously provided, a detailed explanation as to why none has been used and the rationale for the student’s current need for accommodations must be provided.

It is important to recognize that accommodation needs can change over time and are not always identified through the initial diagnostic process. Conversely, a prior history of an accommodation does not, in and of itself, warrant the provision of a similar accommodation at the postsecondary level. Final determination for providing appropriate and reasonable accommodations rests with the institution. 


Guidelines for Documentation of a Mobility, Sensory or Chronic Medical Disability

Each student requesting accommodations through the office of Disability Resource Center is required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA). As defined by Section 504 and the ADA , an individual with a disability is a person who has a physical or mental impairment which substantially limits a major life activity, including learning. Academic adjustments and other accommodations are implemented to provide equal access to college programs and services.

In order to establish eligibility as an individual with a disability, the student must submit documentation that is comprehensive and clearly specifies the presence of a disability, and is appropriate to the post-secondary setting.

Any specific recommendations for accommodations must be based on significant functional limitations and must be supported by the diagnostic assessment. Accommodations and academic adjustments cannot be implemented until the student’s documentation meets these criteria. Prior history of having received an accommodation does not, in and of itself, warrant or guarantee its continued provision. An Individualized Education Plan (IEP) is not sufficient documentation of a disability.

Documentation of a mobility, sensory, or chronic medical disability must be provided by a doctor or other medical professional with training and expertise related to the particular medical condition identified. The diagnostic report must be submitted on official letterhead with name(s), title(s), professional credentials, address, and telephone number of the person providing the documentation. All reports must be signed and dated.

Documentation must include the following information:

  • Diagnosis – A current medical diagnosis including appropriate medical reports, relevant medical history, and a clinical summary.
  • Current Treatment – Identification of treatment, medications, assistive devices, or other services currently prescribed or in use.
  • Evaluation of Impact – Identification of the substantial limitation on a major life activity presented by the disability, and a description of the current functional impact of the disability in a college setting. The assessment should validate the need for services based on the impact of the student’s disability and level of functioning in an educational setting.
  • Specific Recommendations – Suggested accommodations and/or academic adjustments, with an explanation supporting the need for each accommodation to achieve equal access. 

Guidelines for Documentation of Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder

Each student requesting accommodations through the Disability Resource Center is required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act Amendments Act (ADAAA).  As defined by Section 504 and the ADA, an individual with a disability is a person who has a physical or mental impairment which substantially limits a major life activity, including learning.  Academic adjustments and other accommodations are implemented to provide equal access to college programs and services.

In order to establish eligibility as an individual with a disability, the student must submit documentation that is comprehensive, clearly specifies the presence of a disability, and is appropriate to the post-secondary setting.

Any specific recommendations for accommodations must be based on significant functional limitations and must be supported by the diagnostic assessment.  Accommodations and academic adjustments cannot be implemented until the student’s documentation meets these criteria.  Prior history of having received an accommodation does not, in and of itself, warrant or guarantee its continued provision.  An Individualized Education Plan (IEP) or 504 Plan is not sufficient documentation of a disability.

Documentation for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) must be from an appropriate professional with comprehensive training in differential diagnosis as well as direct experience working with adolescents and adults with ADD/ADHD.  Professionals considered qualified to evaluate and diagnose ADD/ADHD include clinical psychologists, neuropsychologists, psychiatrists, and other relevantly trained medical doctors, such as neurologists.  The diagnostic report should be typed and submitted on official letterhead with name, title, professional credentials, address, and phone/fax numbers of the evaluator.  The

  • A specific diagnosis of ADD or ADHD based on DSM-IV diagnostic criteria, date of the current diagnostic evaluation, and the date of the original diagnosis.
  • Evidence of current impairment.  An assessment of the individual’s presenting symptoms and evidence of current hyperactive or inattentive behaviors that significantly impair functioning must be provided. 
  • Relevant developmental, medical and medication history, a thorough academic history, and a review of prior psycho-educational test reports to determine whether a pattern of strengths or weaknesses is supportive of attention or learning problems should be included.
  • A summary of relevant assessment data that supports or refutes a diagnosis of ADD/ADHD. Diagnostic assessment must consist of more than a self-report.  Possible data sources include results from the Continuous Performance Test, the T.O.V.A., Trail Making Test, or a neuropsychological evaluation.  Assessments such as checklists and rating scales are valuable, but should not be used as the sole criterion for a diagnosis of ADD/ADHD.
  • Evidence of alternative diagnoses or explanations being ruled out.  The documentation must investigate and discuss the possibility of dual diagnoses and alternative or coexisting mood, behavioral, neurological, and/or personality disorders that may confound the ADD/ADHD diagnosis.
  • Neurological or psycho-educational assessment may be necessary in order to determine the current impact of the disorder on the individual’s ability to function in an academic setting and to establish eligibility for classroom accommodations, including alternative testing, note-takers, etc.  Such data should include subtest and standard scores.
  • An indication of whether or not the student was evaluated while on medication and the degree to which the prescribed treatment reduces the level or degree of impairment.
  • A clinical summary which: (a) indicates the substantial limitation to a major life activity posed by the disability, (b) describes the extent to which these limitations would impact the student in an academic setting, (c) suggests how the specific effects of the disability may be accommodated, and (d) states how the effects of the ADD/ADHD are mediated by the recommended accommodations.

Guidelines for Documentation of a Psychological Disability 

Each student requesting accommodations through the office of Disability Resource Center is required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA). As defined by Section 504 and the ADA , an individual with a disability is a person who has a physical or mental impairment which substantially limits a major life activity, including learning. Academic adjustments and other accommodations are implemented to provide equal access to college programs and services.

In order to establish eligibility as an individual with a disability, the student must submit documentation that is comprehensive and clearly specifies the presence of a disability, and is appropriate to the post-secondary setting.

Any specific recommendations for accommodations must be based on significant functional limitations and must be supported by the diagnostic assessment. Accommodations and academic adjustments cannot be implemented until the student’s documentation meets these criteria. Prior history of having received an accommodation does not, in and of itself, warrant or guarantee its continued provision. An Individualized Education Plan (IEP) is not sufficient documentation of a disability.

Documentation of a psychological disability must be current, reporting on the student’s status within the past year. More recent documentation may be required if deemed necessary by the disability services personnel in the office of Disability Resource Center. Documentation must be provided by a psychiatrist, psychologist, social worker, or other mental health professional with training and expertise related to the diagnosis identified. The diagnostic report must be submitted on official letterhead with name(s), title(s), professional credentials, address, and telephone number of the person providing the documentation. All reports must be signed and dated.

Documentation must include the following information:

  • Diagnosis – a complete DSM-IV diagnosis with an accompanying description of the specific symptoms experienced by the student. The diagnosis should be based upon a comprehensive clinical interview and, where clinically appropriate, psychological testing.
  • Current Treatment – Identification of treatment, medications, or other services and/or interventions currently prescribed or in use.
  • Evaluation of Impact – Identification of the substantial limitation on a major life activity presented by the disability, and a description of the current functional impact of the disability in a college setting. The assessment should validate the need for services based on the impact of the student’s disability and level of functioning in an educational setting.
  • Specific Recommendations – Suggested accommodations and/or academic adjustments, with an explanation supporting the need for each accommodation to achieve equal access. Diagnostic information must support the need for the recommended accommodations.

Guidelines for Documentation of an Autism Spectrum Disorder

Each student requesting accommodations through the Disability Resource Center is required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA).  As defined by Section 504 and the ADA, an individual with a disability is a person who has a physical or mental impairment which substantially limits a major life activity, including learning.  Academic adjustments and other accommodations are implemented to provide equal access to college programs and services.

In order to establish eligibility as an individual with a disability, the student must submit documentation that is comprehensive and clearly specifies the presence of a disability, and is appropriate to the post-secondary setting.

Any specific recommendations for accommodations must be based on significant functional limitations and must be supported by the diagnostic assessment.  Accommodations and academic adjustments cannot be implemented until the student’s documentation meets these criteria.  Prior history of having received an accommodation does not, in and of itself, warrant or guarantee its continued provision.  An Individualized Education Plan (IEP) is not sufficient documentation of a disability.

Documentation of an autism spectrum disorder (Asperper’s Syndrome and other pervasive developmental disorders) should be current.  In most cases, this means completed within the past three years.  The evaluation must be performed by a professional who has training and direct experience working with adults on the autism spectrum.  This would include psychiatrists, neurologists, clinical psychologists, neuropsychologists, etc.  Diagnostic reports must be on official letterhead and include the name, title, and professional credentials of the evaluator.  All reports must be signed and dated.

The diagnosis of an autism spectrum disorder does not rely on one test or a specific battery of tests.  As a result, it requires a multi-faceted approach.  The guidelines that follow are provided to assure that evaluation reports are fair and appropriate to determine eligibility. 

Documentation must include the following information:

  • Diagnosis – a complete DSM-IV diagnosis with an accompanying description of the specific symptoms experienced by the student and their impact on academic, social, behavioral and emotional functioning.  The diagnosis should be based upon a comprehensive clinical interview and, where clinically appropriate, psychological testing.
  • Current Treatment – Identification of treatment, medications, or other services and/or interventions currently prescribed or in use.
  • Evaluation of Impact – Identification of the substantial limitation on a major life activity presented by the disability, and a description of the current functional impact of the disability in a college setting.  The assessment should validate the need for services based on the impact of the student’s disability and level of functioning in an educational setting.
  • Specific Recommendations – Suggested accommodations and/or academic adjustments, with an explanation supporting the need for each accommodation to achieve equal access.  Diagnostic information must support the need for the recommended accommodations.