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The following guidelines from the Association on Higher Education and Disabilities provide the components of documentation necessary to establish eligibility for services and receiving appropriate accommodations.
The best quality documentation is provided by a licensed or otherwise properly qualified professional who has undergone appropriate and comprehensive training, has relevant experience, and has no personal relationship with the individual being evaluated. A good match between the credentials of the individual making the diagnosis and the condition being reported is expected. (e.g., an orthopedic limitation might be documented by a physician, but not a licensed psychologist. All reports must have the name and signature of the evaluator and their title.
Quality documentation includes a clear diagnostic statement that describes how the condition was diagnosed, provides information on the functional impact, and details the typical progression and/or prognosis of the condition. While complete multiaxial information and codes from the current Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association or the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization are required in providing this information, a full clinical description will convey the necessary information.
Quality documentation includes a description of the diagnostic criteria, evaluation methods, procedures, tests and dates administered, as well as a clinical narrative, observations, and specific results. Where appropriate to the nature of the disability, having both summary data and specific test scores (with the norming population identified) within the report is recommended.
Information on how the disabling condition(s) currently impacts the individual provides useful information for both establishing a disability and identifying possible accommodations. A combination of the results of formal evaluation procedures, clinical narrative, and the individual’s self report is the most comprehensive approach to fully documenting impact. The best quality documentation is through enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition(s).
While relatively recent documentation is recommended in most instances, common sense and discretion in accepting older documentation of conditions that are permanent or non-varying will be considered. Likewise, changing conditions and/or changes in how the conditions impact the individual brought on by growth and development may warrant more frequent updates in order to provide an accurate picture. It is important to remember that the documentation is not time bound. The need for recent documentation depends on the facts and circumstances of the individual condition(s). Wilmington University recognizes that in some cases an updated letter from a qualified professional may simply address why prior documentation that has been submitted continues to be relevant. Re-testing that is not medically necessary can be waived.
It is helpful when documentation provides information on expected changes in the functional impact of the disability over time and context. Information on the cyclical or episodic nature of the disability and known or suspected triggers to episodes provides opportunities to anticipate and plan for varying functional impacts. If the condition is not stable, information on interventions (including the individuals own strategies) for exacerbation and recommended timelines for re-evaluations are helpful.
The most comprehensive documentation will include a description of both current and past medications, auxiliary aids, assistive devices, support services and accommodations, including their effectiveness in ameliorating functional impacts of the disability. A discussion of any significant side effects from current medications or services that impact physical, perceptual, behavioral or cognitive performance is helpful when included in the report. While accommodations provided in another setting are not binding on this institution, they may provide insight in making current decisions.
Recommendations from professionals with a history of working with the individual provide valuable information for the review and the planning process. It is important that recommended accommodations and strategies are logically related to the functional limitations. If relationships are not obvious, a clear relationship will be needed for deciding on an accommodation. While the post-secondary institution has no obligation to provide or adopt recommendation made by outside entities, those that are congruent with the programs, services and benefits offered by the University may be appropriate. When recommendations go beyond equitable and inclusive services and benefits, they may still be useful in suggesting alternative accommodations and/or services.
In addition to the above guidelines, documentation of a learning disability will require a current Psycho-educational evaluation (dated within three years if completed before the student was 18 or within 5 years if completed after the student was 18), administered by someone licensed or certified to do so and containing the following information: