Documentation Guidelines

Please refer to the following documentation guidelines before applying for disability accommodations and support.

General Guidelines

  1. Testing must be current. A student seeking accommodations must provide current documentation (no more than four years old) for a condition which can change over time or which responds to medication. A student seeking accommodation for a condition that does not change over time is encouraged to provide current documentation of his/her condition, however, re-testing may not be medically necessary to evaluate the student's disability. It is advised that students consult the Director of Disability Services for clarification. Because the provision of reasonable accommodations and services is based upon assessment of the current impact of the student's disabilities on his/her academic functioning, it is in a student's best interest to provide recent and appropriate documentation.
  2. Testing should provide clear and specific evidence and identification of a disability.
  3. Documentation should address the impact of the disability on an individuals functioning within the context of the academic and vocational environment. Comprehensive assessment should include consideration of the following (as relevant to the nature of the students disability): physical capacity, neurological functioning, cognitive and psychological/emotional functioning. It is recognized that the type of documentation will differ depending upon the disability. Evaluation of psychological/emotional functioning must be in accordance with DSM-IV-TR criteria. Specific areas of evaluation include (but are not limited to) the following:
    • Endurance
    • Fine & Gross Motor Skills
    • Balance & Postural Control
    • Pain
    • Sensory Registration & Processing
    • Visual Perception
    • Use of Supports
    • Mood & Affect
    • Organizational Skills
    • Problem Solving
    • Coping Skills
    • Memory
  4. Evaluation results and interpretation of results is required.
  5. Documentation must be submitted by a qualified practitioner. Trained, certified and/or licensed physicians, psychologists, learning disabilities specialists, occupational, physical, or speech-language pathologists, and other professionals are representative of clinicians involved in the process of assessment. Diagnostic reports must include the names, titles, and professional credentials of the evaluators as well as the date(s) of testing.
  6. Include specific recommendations for accommodations. Any recommendation for accommodation should be based on objective evidence of a substantial limitation to learning as supported by specific test results or clinical observations. Reports should establish the rationale for any accommodation that is recommended, using test data to document the need.
  7. A description of any accommodation and/or auxiliary aid that has been used in high school or at another institution should be discussed. Include information about the specific conditions under which the accommodation was used (e.g., standardized testing, final exams) and whether or not it was beneficial for the student.
  8. A summary of relevant background information (e.g., educational, medical, and social history) should be provided.
  9. Please Note: Individualized Education/Transition Plans (IEPs/ITPs) are useful, but are not, in and of themselves, sufficient documentation to establish the rationale for accommodations.
  10. Students with a temporary disability, which affects them in classes, must provide medical documentation on a term by term basis.
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Learning Disability Documentation Guidelines

Students who are seeking support services from Middlesex Community College on the basis of a diagnosed specific learning disability are required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the ADA Amendments Act of 2008. Protection under these civil rights statutes is based upon documentation of a learning disability that currently substantially limits some major life activity including learning.

The following guidelines are provided in the interest of assuring that documentation is appropriate to verify eligibility and support requests for reasonable accommodations, academic and/or auxiliary aids on the basis of a learning disability that substantially limits one or more major life activities.

  1. TESTING MUST BE COMPREHENSIVE It is not acceptable to administer only one test for the purpose of diagnosis. Minimally domains to be addressed must include (but not be limited to):
    • Aptitude:
      • Wechsler Adult Intelligence Scale - Revised (WAIS-R) with subtest scores is the preferred instrument.
      • The Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability Stanford-Binet Intelligence Scale: Fourth Edition are acceptable.
    • Achievement:
      • Current levels of functioning in reading, mathematics and written language are required.
      • Acceptable instruments include:
        • Woodcock- Johnson Psychoeducational Battery â€"Revised: Tests of Achievement
        • Wechsler Individual Achievement Test (WIAT);
        • Stanford Test of Academic Skills (TASK);
        • Scholastic Abilities Test for Adults (SATA);
        • Test of Written Language - 2 (TOWL-2),
        • Woodcock Reading Mastery Tests - Revised
        • Stanford Diagnostic Mathematics Test.
    • The following tests are not comprehensive measures of achievement and therefore are not suitable.
      • The Peabody Individual Achievement Test (PIAT) and
      • The Wide Range Achievement Test - Revised or III (WRAT-R or WRAT- III)
    • Information Processing Specific areas of information processing (e.g., short- and long-term memory; sequential memory; auditory and visual perception/processing, processing speed) must be assessed. Information from subtests on the following may be used:
      • WAIS-R
      • Woodcock-Johnson Tests of Cognitive Ability
      • Detroit Test of Learning Aptitude-Adult
      • as well as other instruments relevant to the presenting learning problem(s)
    • 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.
  2. TESTING MUST BE CURRENT In most cases, this means testing that has been conducted within the past three years. Because the provision of all reasonable accommodations and services is based upon assessment of the current impact of the student's disabilities on his/her academic performance, it is in a student's best interest to provide recent and appropriate documentation.
  3. EVIDENCE OF A LEARNING DISABILITY There must be clear and specific evidence and identification of a learning disability. Individual learning styles" and "learning differences" in and of themselves do not constitute a learning disability.
  4. ACTUAL TEST SCORES MUST BE PROVIDED. Standard scores are required; percentiles and grade equivalents must also be included.
  5. QUALIFIED PROFESSIONAL Professionals conducting assessment and rendering diagnoses of learning disabilities must be qualified to do so. Trained, certified and/or licensed school psychologists, neuropsychologists, clinical psychologists, learning disabilities specialists, and other professionals with training and experience relevant to adults and their evaluation are typically involved in the process of assessment. Experience in working with an adult population is essential.
  6. VALID TESTING Tests used to document eligibility must be technically sound (i.e. statistically reliable and valid ) and standardized for use with an adult population.
  7. DIAGNOSTIC REPORT MUST INCLUDE:
    • Name, title, and of evaluators
    • Professional credentials of evaluator(s) (e.g. licensed psychologist)
    • Date(s) of testing
    • All reports must be typed
  8. EVIDENCE OF SUBSTANTIAL LIMITATIONS Any recommendations for an accommodation should be based on objective evidence of a substantial limitation to learning supported by specific test results or clinical observation.
  9. DESCRIPTION OF ACCOMMODATION A description of any accommodation and/or auxiliary aid that has been used at the secondary or postsecondary level should be discussed. Include information about the specific conditions under which the accommodation was used (e.g. standardized testing, final exams) and whether or not it benefited the student. If no accommodations have been previously provided, a detailed explanation as to why none has been used and the rationale for the student's currently needing accommodation(s) must be provided.

Adapted from McGuire,J.M., Anderson, P.L., & Shaw, S.F. (1992; Revised, 1997). Guidelines for Documentation of a Specific Learning Disability. Storrs, CT: University Program for College Students with Learning Disabilities (UPLD). Used with permission.

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Autism Spectrum Disorder Documentation Guidelines

Please provide a Neuropsychological Evaluation, if available. If not, see Learning Disability requirements. back to top

Attention Deficit Hyperactivity Disorder Documentation Guidelines

Download form for documenting ADHD.

INTRODUCTION

Under the ADA Amendments Act of 2008 and Section 504 of the Rehabilitation Act of 1973, individuals with disabilities are protected from discrimination and assured services. In order to establish that an individual is covered under the ADA, the documentation must indicate that the disability substantially limits some major life activity, including learning. The following documentation guidelines are provided in the interest of assuring that documentation of ADHD demonstrates an impact on a major life activity and supports the request for accommodations, and/or services.

DOCUMENTATION GUIDELINES

A QUALIFIED PROFESSIONAL MUST CONDUCT THE EVALUATION Professionals conducting assessments and rendering diagnoses of ADHD must have training in differential diagnosis and the full range of psychiatric disorders. The following information should be clearly stated in the documentation.

  • The name of evaluator
  • Title
  • Professional credentials of the evaluator
  • Information about license or certification
  • Area of specialization,
  • Employment, and state in which the individual practices should be

The following professionals would generally be considered qualified to evaluate and diagnose ADHD provided they have comprehensive training in the differential diagnosis of ADHD and direct experience with an adolescent or adult ADHD population:

  • Clinical psychologists,
  • Neuropsychologists,
  • Psychiatrists, and
  • Other relevantly trained medical doctors, and clinical nurse practitioners.
  • It may be appropriate to use a clinical team approach consisting of a variety of educational, medical, and counseling professionals with training in the evaluation of ADHD in adolescents and adults.

Use of diagnostic terminology indicating an ADHD by someone whose training and experience are not in these fields is not acceptable. All reports should be on letterhead, typed, dated, signed, and otherwise legible.

DOCUMENTATION SHOULD BE CURRENT Because the provision of all reasonable accommodations and services is based upon assessment of the current impact of the disability on academic performance, it is in an individuals best interest to provide recent and documentation.

In most cases, this means that

  • a diagnostic evaluation has been completed within the past three years.
  • If documentation is inadequate in scope or content, or does not address the individuals current level of functioning and need for accommodation(s), reevaluation may be warranted.
  • The update should include a detailed assessment of the current impact of the ADHD and interpretive summary of relevant information (see Section III, G) and the previous diagnostic report.

DOCUMENTATION SHOULD BE COMPREHENSIVE

Evidence of Early Impairment Because ADHD is, by definition, first exhibited in childhood (although it may not have been formally diagnosed) and manifests itself in more than one setting, relevant historical information is essential.

Evidence of Current Impairment Diagnostic Interview

  • The information collected for the summary of the diagnostic interview should consist of more than self-report, as information from third party sources is critical in the diagnosis of ADHD. The diagnostic interview with information from a variety of sources should include, but not necessarily be limited to, the following:
  • History of presenting attentional symptoms, including evidence of ongoing impulsive/hyperactive or inattentive behavior that has significantly impaired functioning over time;
  • Developmental history;
  • Family history for presence of ADHD and other educational, learning, physical, or psychological difficulties deemed relevant by the examiner;
  • Relevant psychosocial history and any relevant interventions;
  • A thorough academic history of elementary, secondary, and postsecondary education;
  • Review of prior psychoeducational test reports to determine whether a pattern of strengths or weaknesses is supportive of attention or learning problems;
  • Relevant employment history;
  • Description of current functional limitations pertaining to an educational setting that are presumably a direct result of problems with attention;
  • Relevant history of prior therapy.

Rule Out Of Alternative Diagnoses Or Explanations The evaluator must investigate and discuss the possibility of dual diagnoses, and alternative or co-existing mood, behavioral, neurological, and/or personality disorders, which may confound the diagnosis of ADHD.

Relevant Testing Neuropsychological or psychoeducational assessment is important in determining the current impact of the disorder on the individuals ability to function in academically related settings.

  • The evaluator should objectively review and include with the evaluation report relevant background information to support the diagnosis.
  • If grade equivalents are reported, they must be accompanied by standard scores and/or percentiles.
  • Test scores or subtest scores alone should not be used as a sole measure for the diagnostic decision regarding ADHD.
  • Selected subtest scores from measures of intellectual ability, memory functions tests, attention or tracking tests, or continuous performance tests do not in and of themselves establish the presence or absence of ADHD.
  • Checklists and/or surveys can serve to supplement the diagnostic profile but in and of themselves are not adequate for the diagnosis of ADHD and do not substitute for clinical observations and sound diagnostic judgment.
  • All data must logically reflect a substantial limitation to learning for which the individual is requesting the accommodation.

Identification Of DSM-IV Criteria According to the DSM-IV, "the essential feature of ADHD is a persistent pattern of attention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development" (p.78). A diagnostic report should include a review and discussion of the DSM-IV criteria for ADHD both currently and retrospectively and specify which symptoms are present.

Documentation Must Include A Specific Diagnosis The report must include a specific diagnosis of ADHD based on the DSM-IV diagnostic criteria. The diagnostician should use direct language in the diagnosis of ADHD, avoiding the use of terms such as "suggests," "is indicative of," or "attention problems."

Individuals who report only problems with organization, test anxiety, memory and concentration in selective situations do not fit the diagnostic criteria for ADHD. Given that many individuals benefit from prescribed medications and therapies, a positive response to medication by itself does not confirm a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodation(s).

An Interpretative Summary Should Be Provided A well-written interpretative summary based on a comprehensive evaluative process is a necessary component of the documentation.

Adapted from Consortium on ADHD Documentation, 1998. Used with permission.

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Medical/Sensory Disability Documentation Guidelines

Download form for documenting a medical/sensory disability.

Students who are seeking support services from Middlesex Community College on the basis of a diagnosed physical disability are required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the ADA Amendments Act of 2008.  Protection under these civil rights statutes is based upon documentation of a physical disability that currently substantially limits some major life activity including learning.

The following guidelines are provided in the interest of assuring that documentation is appropriate to verify eligibility and supports a request for reasonable accommodations, academic and/or auxiliary aids on the basis of a physical disability that substantially limits one or more major life activities.

For students with visible disabilities (ex: students with mobility challenges), the individual should provide current documentation from a licensed medical professional which discloses

(a) the nature of the disability; (b) the functional limitations in an educational environment; (c) prognosis, when appropriate; and (d) recommendations in an educational setting. 

For students with non-visible physical or medical disabilities (ex: arthritis, ulcerative colitis) the individual should provide current documentation from a licensed medical professional, which discloses (a) the nature of the disability; (b) the functional limitations resulting from the disability in an educational environment; (c) prognosis, when appropriate; and (d) recommended accommodations.

 For students with sensory impairments (vision or hearing), the individual should provide current documentation from a licensed medical professional which indicates (a) diagnosis, including the extent of the vision or hearing impairment; (b) the functional limitations resulting from the disability in an educational environment; (c) prognosis, when appropriate; and (d) recommended accommodations, including assistive technology.

 NOTE: For students who are experiencing a temporarily disabling condition. Although students with temporary disabilities or illnesses may not be considered disabled under federal law, they may sometimes need accommodations similar to those provided to students with permanent disabilities.  To receive an accommodation, a student must present documentation of their temporary disability from a qualified medical professional.  Such documentation should include an estimate of the length of time the student will require accommodations in the educational setting.  Reasonable accommodations will be made beginning when the request is made and documented.  These accommodations will NOT be retroactive.

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Psychiatric Disability Documentation Guidelines

Download form for documenting a psychiatric disability.

Introduction
Psychiatric disabilities comprise a range of conditions characterized by emotional, cognitive, and/or behavioral dysfunction. A diagnosis by a licensed mental health professional including psychologists, neuropsychologists, psychiatrists, neuropsychiatrists, other relevantly trained medical doctors, clinical social workers, licensed counselors, and psychiatric nurse practitioners is required. The diagnostician must be an impartial individual who is not a family member of the student. The name, title, and credentials of the qualified professional writing the report should be included. Documentation for eligibility must reflect the current impact the disability 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).

Documentation should include:

A clear statement of the students disability. This statement should include a DSM-IV-TR diagnosis, including global assessment of functioning, and a summary of present symptoms. A summary of assessment procedures and evaluation instruments used to make the diagnosis, including evaluation results and standardized scores if applicable.

A description of the current functional limitations in the academic environment as well as across other settings. This may include a history of presenting symptoms, duration and severity of the disorder, and relevant historical and familial data.

Medical information relating to the student's needs, including the impact of medication on the student's ability to meet the demands of the postsecondary environment. This should include the current medication regimen and side effects (if relevant).

Relevant information regarding current treatment.

Suggested accommodations with accompanying rationale. A link must be established between the suggested accommodations and the functional limitations of the student in the academic environment. A diagnosis in and of itself does not automatically warrant approval of requested accommodations.

The student and disability support services will work collaboratively to determine appropriate accommodations.

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Last Modified: 5/10/17