Documentation Guidelines
- Attention Deficit Hyperactivity Disorder
- Learning Disabilities
- Chronic/Systemic Illness
- Orthopedic Impairments
- Deaf and Hard of Hearing
- Psychiatric Disorders
- Visual Disorders
- Traumatic Brain Injury
These publications are available in alternative format upon request.
Introduction
Students seeking services from Disability Resources and Services on the basis of a disability are required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990. Protection under these civil rights statutes is based upon documentation of a current disability that substantially limits a major life function.
When the documentation is received at DRS and reviewed, a staff member works with the individual to determine reasonable and appropriate accommodations. DRS creates a Notification of Disability Memo to inform instructors of the recommended accommodations. It is the student's responsibility to deliver a Notification Memo to each instructor and to discuss the implications of these accommodations on the fulfillment of course requirements.
Criteria for the source, scope and content of the documentation differs by disability. Refer to the following Guidelines for Disabilities for the specifics on several types of disability.
Attention Deficit Hyperactivity Disorder
Documentation requirements for an individual requesting services due to an attentional disorder must be completed by a psychiatrist, psychologist, or other related medical professional with the experience or expertise in the domain for which he/she is diagnosing. Reports must be on letterhead, typed, dated, and signed.
There is no one test or specified combination of tests for determining ADHD. An accurate diagnosis requires a multifaceted approach. Test scores or subtest scores cannot be used alone to make a diagnosis. A report based on a clinical interview alone will not meet the guidelines. Consider the combinations of elements that are listed below as possible guidelines for writing reports:
- Clinical interview + history + computerized continuous performance test + tests of cognitive ability
- Clinical interview + history + computerized continuous performance test + additional neuropsychological assessment measures
- Clinical interview + history + rating scales + response to medication
- Psychoeducational battery that meets the University of Pittsburgh's established documentation guidelines for a learning disorder (see LD guidelines)
Clarification of elements:
- Clinical interview must include:
- Current symptoms as described by the DSM-IV TR
- Treatment of the disorder
- Differential diagnoses that were excluded and rationale for
excluding them - History must include:
- Evidence of early impairment
- Relevant medical, family, and academic history
- Computerized continuous performance test - examples are:
- TOVA
- IVA CPT
- Conners CPT
- Rating scales - examples are:
- Brown Attention-Activation Disorder Scale
- Wender Utah Rating Scale
- ADHD Rating Scale (ARS)
- Tests of cognitive ability - examples include:
- Woodcock-Johnson Tests of Cognitive Ability
- WAIS III
The documentation must include these components to be complete:
- A DSM-IV TR diagnosis
- An interpretation of test scores
- A description of the condition's current functional impact on learning
- Medication dosage, frequency, and possible side effects (if applicable)
- Medication effects on attention (if applicable)
- Testing must reflect adult status (18 years or older) and is considered to be valid if administered within the last three years
Chronic/Systemic Illness
Chronic and/or systemic illnesses are considered to be in the medical domain and therefore the documentation must be completed by a physician, neurologist, physiatrist, or other medical specialist with experience or expertise in the domain for which he/she is diagnosing. Comprehensive documentation must be submitted that includes:
- A clear statement of the existence of a medically determinable chronic illness or systemic illness;
- A written report of:
- A detailed medical history
- A complete physical examination (including a mental status examination)
- Medical evidence consisting of medical signs, symptoms (duration, incidence and severity) and laboratory findings
- Proof of a substantial reduction in previous levels of occupational, educational, social, or personal activities
- Results of diagnostic test battery performed to rule out other causes of symptoms
- A description of the condition's current functional impact on learning or other major life activity relevant to the academic experience;
- A statement addressing the individual's requested accommodation(s), including rationale as to why these accommodation(s) are warranted*;
- A statement regarding how the use of medication or other rehabilitative measures may or may not mitigate either the illness or the symptoms associated.
* Any request for an extension of time on examinations, based on the impairment, should be supported by evidence that reflects a measurable decline in pre-morbid functioning.
Deaf or Hard of Hearing
Documentation requirements for an individual requesting services due to a partial or complete hearing loss must be completed by an otolaryngologist, otologist, or other medical specialist with the experience or expertise in the domain for which they are diagnosing. Audiologists may also provide current audiograms. Comprehensive documentation must be submitted that includes:
- A clear statement of deafness or hearing loss;
- Results of a current audiogram with a narrative interpretation;
- A summary of assessment procedures and evaluation instruments used to make the diagnosis;
- Medical information relating to the status of the individual's hearing (static or changing);
- A description of the functional impact or limitations the hearing loss may have on learning or other major life activity relevant to the academic experience;
- A statement addressing the individual's requested accommodation(s) taking into account the preferred method of communication, and include a rationale as to why these accommodation(s) are warranted;
- A statement regarding the use of hearing aids (if appropriate) or other corrective measures that may or may not mitigate the impairment.
Learning Disabilities
To be appropriately diagnosed, learning disorders require the expertise of a psychologist, neuropsychologist, or other related professional with experience and expertise in the area for which he/she is diagnosing a disability and recommending accommodations. The following guidelines must be followed to ensure that the diagnostic evaluation is appropriate for establishing eligibility, verifying accommodation needs, and determining academic adjustments.
- Testing necessary to substantiate a learning disability must be comprehensive. When selecting a battery of tets, it is critical to consider the technical adequacy of instruments, including their reliability, validity, and standardization on an appropriate norm group. Cognitive functioning in the following domains must be assessed by one of the following instruments:
- Aptitude
- Wechsler Adult Intelligence Scale-III (WAIS-III)|
- Woodcock-Johnson Psychoeducational Battery-Revised:
Tests of Cognitive Ability (WJ-R) - Achievement
Current levels of functioning in reading, mathematics and written language are required. - Woodcock-Johnson Psychoeducational Battery-Revised: Tests of Achievement
- Stanford Test of Academic Skills (TASK)
- Scholastic Ability Test for Adults (SATA
- Wechsler Individual Achievement Test (WIAT) or a combination of specific achievement tests such as:
- Test of Written Language-2 (TOWL-2)
- Woodcock Reading Mastery Test-Revised
- Stanford Diagnostic Mathematics Test
- Nelson Denny Reading Test
- Information Processing
Specific areas of cognitive processing must be assessed. - Wechsler Adult Intelligence Scale-III (WAIS-III)
- Woodcock-Johnson Psychoeducational Battery- Revised:Tests of Cognitive Ability
- Halstead-Reitan Neuropsychological Battery
- Testing must reflect adult status (18 years and over) and is considered valid if administered within the last five years. The provision of accommodations is based upon the disability's current impact on an individual's ability to learn.
- Documentation must provide clear and specific evidence of a learning disability and include a diagnostic statement.
- Evidence must be included that addresses alternative explanations for problems in learning such as emotional, attentional, or motivational problems.
- Individual "learning styles", "learning problems", "learning differences", "slow reader", and "test difficulty or test anxiety", in and of themselves, do not constitute a learning disability.
- Standard scores and percentiles must be included for all normative measures.
- Data must support a statistically significant limitation to learning.
- Grade equivalents are not acceptable unless standard scores and/or percentiles are included.
- A narrative report should include:
- Summary of a comprehensive diagnostic interview;
- Summary of student self report, interview with others, and historical documentation such as standardized test scores and transcripts;
- Description of the presenting problems(s);
- Developmental history, relevant family history, medical history, and relevant psychiatric history
- Diagnostic evaluation must include a statement addressing the individual's requested accommodation(s) and rationale as to why these accommodation(s) are warranted.
Orthopedic Impairments
Documentation requirements for an individual requesting services due to any type of orthopedic impairment must be completed by a physician, physiatrist, orthopedist, or other medical specialist with the experience or expertise in the domain for which he/she is diagnosing. Comprehensive documentation must be submitted that includes:
- A clear statement of the existence of a medically determinable orthopedic impairment;
- A written report of:
- A detailed medical history
- Results of a complete physical examination
- Medical evidence consisting of medical signs, symptoms (duration, -incidence and severity) and laboratory findings
- Proof of a substantial reduction in previous levels of movement
- Results of diagnostic test battery performed to rule out other causes of symptoms
- A description of the condition's current functional impact on learning or other major activity relevant to the academic experience;
- A statement addressing the individual's requested accommodation(s), including rationale as to why these accommodation(s) are warranted*;
- A statement regarding the use of any corrective devices or other rehabilitative measures, including medication that may or may not mitigate the orthopedic impairment.
* Any request for an extension of time on examinations based on the impairment should be supported by evidence that reflects a measurable decline in pre-morbid functioning.
Psychiatric Disabilities
Documentation requirements for an individual requesting services due to a psychiatric or psychological illness must be completed by a licensed clinical social worker, licensed professional counselor, psychologist, psychiatrist, neurologist, or other medical specialist with experience or expertise in the domain for which he/she is diagnosing. Comprehensive documentation must be submitted that includes:
- A clear statement of the existence of a psychiatric impairment, including a DSM-IV-TR diagnosis;
- A written report of:
- History of presenting symptoms
- Relevant developmental and familial information
- Relevant medical history
- Duration and severity of the disorder
- Current treatments
- A description of the condition's current functional impact on learning or other major life activity relevant to the academic experience;
- A statement addressing the individual's requested accommodation(s), including rationale as to why these accommodation(s) are warranted*;
- A statement regarding how the use of medication and/or psychotherapy may or may not mitigate the psychiatric/psychological disorder.
* Any request for an extension of time on examinations, based on the impairment, should be supported by evidence that reflects a measurable decline in pre-morbid functioning.
Visual Disorders
Documentation requirements for an individual requesting services due to a visual disorder (blind or low vision) must be completed by an ophthalmologist or other medical specialist with the experience or expertise in the domain for which he/she is diagnosing.
Comprehensive documentation must be submitted that includes:
- A clear statement of a vision-related disorder;
- A summary of the assessment procedures and evaluation instruments used to make the diagnosis, including standardized scores if appropriate;
- Present symptoms that meet the criteria for the diagnosis;
- Medical information relating to the status of the individual's vision (static or changing);
- A description of the condition's current functional impact on learning or other major life activity relevant to the academic experience;
- A statement addressing the individual's requested accommodation(s), including rationale as to why these accommodation(s) are warranted;
- A statement regarding how the use of corrective lenses, technology, or ongoing visual therapy may or may not mitigate the visual disorder.
Traumatic Brain Injury
A head injury or traumatic brain injury are considered to be in the medical domain and therefore the documentation must be completed by a physician, neurologist, neuropsychologist, psychiatrist, or other medical specialist with experience or expertise in the domain for which he/she is diagnosing. Documentation should be current, preferably within the past three years, however, this is dependent upon the disabling condition, the current status of the student and the student's request for accommodations.
Comprehensive documentation must be submitted that includes:
- A clear statement of the head injury or traumatic brain injury and the probable site of lesion;
- A written report of:
- Results of a complete physical examination (including a mental status
examination) - A summary of cognitive and achievement measures used and evaluation results, including standardized scores or percentiles
- A summary of present residual symptoms
- Proof of a substantial reduction in previous levels of occupational, educational, social, or personal activities
- Medical information relating to student's needs, including the impact of medication on the student's ability to meet the demands of the postsecondary environment
- A description of the current functional impact the head injury has on learning or other major life activity relevant to the academic experience;
- A statement addressing the individual's requested accommodation(s),
including rationale as to why these accommodation(s) are warranted*;
* Any request for an extension of time on examinations, based on the impairment should be supported by evidence that reflects a measurable decline in pre-morbid functioning.