Disability Services Guidelines for Documentation

All documentation should:

• Be on official letterhead, typed and signed by the appropriate credentialed professional.
• Be current. Generally, this means that documentation for ADHD and learning disabilities is determined using assessment tools that have been normed on adults (not children). For mental health disabilities, it is preferable to have documentation from within the 12-months during which the request is being made. Student Disability Services (SDS) reserves the right to make appropriate modifications to this time frame, as appropriate.
• Include a clear diagnostic statement provided by a properly credentialed professional that establishes the existence of a diagnosis and includes the degree to which the student’s diagnosis substantially limits a major life activity and the manner in which the diagnosis limits the individual’s ability to function in the academic environment.
• Provide a description of the diagnostic methodology, including but not limited to test scores, objective medical data, clinical observations, past academic or professional history, and the student’s actual performance in similar situations.

If recommendations are made, these should include a description of the specific accommodations being recommended and a rationale for each as to why the accommodations may be needed based upon the student’s functional limitation(s).

• E.g.: A request for extended time on tests should have documentation that demonstrates significant limitations when taking tests under timed conditions. In most cases, the documentation should include scores from both timed and extended/untimed tests, to demonstrate any difference caused by the timed conditions.
• Please note: If extended test-taking time is suggested, the inability to complete an exam is not always a sufficient rationale since this does not address the academic need for the accommodation as related to the student’s functional limitation and disability.

There are multiple ways to provide documentation of a disability. Documentation will assist Student Disability Services in understanding how the disability impacts the student in the post-secondary setting and the current impact as it relates to the accommodations requested.

Generally, a doctor’s prescription note pad, or a K-12 school plan, such as an IEP or 504 Plan is not sufficient documentation alone, but can be included as part of a more comprehensive evaluative report. Likewise, a physician's letter or note in and of itself typically is not sufficient to establish a substantial limitation related to an Attention-Deficit/Hyperactivity Disorder (ADHD) or many other disabilities.

The Americans with Disabilities Amendment Act of 2008 broadened the definition of disability in the number and types of conditions that could be considered. The updated law also strengthened the importance of quality, detailed documentation in determining who is eligible for accommodations. Many conditions may now be considered a disability, but in order to qualify for accommodations, a major life function must be significantly, amply or substantially limited in the post-secondary environment.

Specific graduate, professional, and/or licensure testing (i.e. GRE, LSAT, NCLEX) may require more up-to-date documentation. Each testing agency provides a description of the required documentation. Accommodation approval from Westminster University does not guarantee accommodation with these testing providers.

All determinations for accommodations and disability eligibility are made on a case-by-case basis by the staff in Student Disability Services in consultation with the individual student.

In addition to the general guidelines listed above, it is recommended that documentation for a specific disability also include the following:

1. A qualified diagnostician must conduct the evaluation
   • Professionals conducting assessments and rendering diagnoses of ADHD must be qualified to do so
   • Comprehensive training in the differential diagnosis of ADHD and direct experience in diagnosis and treatment of adolescents and adults with ADHD is necessary.
2. Evaluation report must include specific information:
   • Date(s) of assessment
   • Clear diagnosis utilizing the appropriate DSM-5 or ICD code(s)
   • A description of the exact symptoms and criteria met for the diagnosis as well as absence of specific diagnostic criteria for ADHD, if applicable.
   • Identification of tools used for diagnostic purposes
   • Clinical observations
   • Relevant pharmacological history, explanation of the extent to which the medication(s) currently benefit and effect the student
   • Testing results using adult norms and reporting as percentiles or stanines, along with standard scores
   • Description of the functional impact as it pertains to the learning environment
   • Details about the typical progression or prognosis of the condition
3. Evidence to support a childhood onset of symptoms and associated diagnosis
   • Historical information regarding the individual's developmental, academic and behavioral functioning in elementary and secondary education, including difficulties and/or use of accommodations in kindergarten through high school and college
   • Review of relevant educational records, early psycho-educational testing reports; documentation from tutors or learning specialists; and disciplinary records
4. Documentation should build a case and provide a rationale for the ADHD diagnosis
   • In-depth history reflecting a chronic and pervasive history of ADHD symptoms and associated diagnosis beginning during childhood and persisting to the present day
   • Description and emphasis on how ADHD symptoms have manifested across various settings over time, how the student has coped with the impacts/limitations and what success the student has had in their coping efforts
   • All co-morbid issues should be addressed and the manner in which they impact the diagnosis or need for accommodations should also be discussed
   • A thorough explanation of the significant functional limitation(s) to major life activities (e.g. learning, concentrating, thinking) posed by the disability
   • Description of the degree to which the functional limitations apply to the life activity for which accommodations are being requested
5. Comprehensive testing battery and diagnostic report with specific assessment data should be included
   • Summary of the assessment procedures and evaluation instruments used to make the diagnosis.
   • An intellectual assessment including sub-test scores, standard scores and percentiles or stanines
     • Examples of acceptable IQ Tests:
       • Kaufman Adolescent and Adult Intelligence Test
       • Reynolds Intellectual Assessment Scales (RIAS)
       • Stanford Binet – 5th Edition
       • Wechsler Adult Intelligence Score-IV (WAIS-IV)
       • Woodcock-Johnson III, Tests of Cognitive Abilities, General Intellectual Ability (WJ-III)
     • Please check with SDS if you are unsure if an assessment tool is acceptable by our standards
   • A comprehensive academic achievement battery with all sub-test scores, standard scores and percentile or stanines reported, and should include current levels of academic functioning in such relevant areas as reading
     • Examples of acceptable Achievement Tests:
       • Scholastic Abilities Test for Adults (SATA)
       • Stanford Test of Academic Skills (TASK)
       • Wechsler Individual Achievement Test III (WIAT-III)
       • Woodcock-Johnson III Psycho-educational Battery: Test of Achievement (WJ-III)
       • Woodcock Reading Mastery Tests – Revised
       • Nelson-Denny Reading Testing (to be used as supplemental test)
   • Test data should logically reflect a substantial limitation to learning for which the student is requesting the accommodation
   • The particular profile of the student's strengths and weaknesses must be shown to relate to functional limitations that may necessitate accommodations
   • Checklists and/or ADHD symptom rating scales can be a helpful supplement in the diagnostic process, but by themselves are not adequate to establish a diagnosis of ADHD
   • Test scores or sub-test scores alone should not be used as a sole measure for the diagnostic decision regarding ADHD as they do not in and of themselves establish the presence or absence of ADHD
6. Each accommodation recommended must include a rationale
   • Accommodations are not granted on the basis of a diagnostic label; instead, accommodation requests need to be tied to evidence of a current functional limitation that supports their use.
   • Each recommendation should be tailored to the individual and tied to specific test results and clinical observations

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
• The student’s history with and managing hearing loss
• The type of hearing loss (conductive or sensorineural)
• The status of the individual’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 are appreciated

1. A qualified diagnostician must conduct the evaluation
   • Professionals conducting assessments and rendering diagnoses of a Learning Disability must be qualified to do so.
   • Comprehensive training and direct experience in diagnosis and treatment of adolescents and adults with LD is necessary.
2. Documentation must be current
   • Although LD is normally viewed as lifelong, the severity and manifestations of the condition may change over time.
   • The provision of reasonable accommodations and services is based upon assessment of the current impact of the disability on the activity in question.
   • Therefore, it is necessary to provide "current," relevant, and appropriate documentation.
3. Evaluation report must include specific information
   • Date(s) of assessment
   • A clear diagnosis utilizing the appropriate DSM-5 or ICD code(s)
   • Identification of tools used for diagnostic purposes
   • Diagnostic interview and clinical observations
   • Testing results using adult norms and reporting as percentiles or stanines, along with standard scores
   • Description of the functional impact and severity of the disorder as it pertains to the learning environment
4. Historical information that might support a childhood onset of symptoms and associated diagnosis
   • Historical information regarding the individual's developmental, academic, and behavioral functioning in elementary and secondary education, including difficulties and/or use of accommodations in kindergarten through high school and college
   • Review of relevant educational records, early psycho-educational reports, documentation from tutors or learning specialists, parental reports, self-report, and disciplinary records
5. Rule Out
   • All co-morbid issues should be addressed and the manner in which they impact the diagnosis or need for accommodations should also be discussed
   • A thorough explanation of the significant functional limitation(s) to major life activities (e.g. learning, concentrating, thinking) posed by the disability
   • Description of the degree to which the functional limitations apply to the life activity for which accommodations are being requested
6. Comprehensive evaluation and diagnostic report with specific assessment data is recommended
   • Summary of the assessment procedures and evaluation instruments used to make the diagnosis
   • An intellectual assessment including sub-test, standard scores and percentiles or stanines.
     • Examples of acceptable IQ Tests are:
       • Kaufman Adolescent and Adult Intelligence Test
       • Reynolds Intellectual Assessment Scales (RIAS)
       • Stanford Binet – 5th Edition
       • Wechsler Adult Intelligence Score-IV (WAIS-IV)
       • Woodcock-Johnson III, Tests of Cognitive Ability (WJ-III)
   • Please check with SDS if you are unsure if an assessment tool is acceptable by our standards.
   • A comprehensive academic achievement battery with all sub-test, standard scores and percentiles or stanines reported, and should include current levels of academic functioning in such relevant areas as reading (decoding and comprehension), mathematics, and oral and written language.
     • Examples of acceptable Achievement Tests include:
       • Scholastic Abilities Test for Adults (SATA)
       • Stanford Test of Academic Skills (TASK)
       • Wechsler Individual Achievement Test III (WIAT-III)
       • Woodcock-Johnson III, Tests of Achievement (WJ-III)
       • Woodcock Reading Mastery Tests – Revised
       • Nelson-Denny Reading Testing (to be used as supplemental test)
7. Each accommodation recommended must include a rationale.
   • If recommendations are made, information that supports the need for each requested accommodation must be provided. The rationale should explain why the specific accommodation is needed based upon functional limitations established through the evaluation process.

Letter or report from a physician in an appropriate medical specialization that includes the following:

• The specific medical condition which causes the disability
• 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(s) for which accommodations are being requested
• Recommendations and rationales for reasonable academic/clinical accommodations may be helpful

Psychological or neuropsychological evaluation or report from a psychiatrist, licensed psychologist, or a therapist that includes the following:

• Clear statement of the condition with the DSM-5 or ICD-10 diagnosis
• Clear description of the specific symptoms experienced by the student which meet the criteria for the diagnosis
• A summary of the assessment procedures and evaluation instruments which were used to make the diagnosis
• Information about currently 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/clinical/residential context for which accommodations are being requested
• If recommendations are being made, rationales for reasonable academic accommodations should be included

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 academic accommodations, rationales should be provided