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Disability Documentation Guidelines

Who is Eligible for Services

To be eligible for Disability Support Services, a student must have a disability as it is defined by federal legislation (Section 504 of the 1973 Rehabilitation Act and the 1990 Americans with Disabilities Act): a disability is any physical or mental condition that causes substantial limitations to the ability to perform one or more major life activities. Major life activities include, but are not limited to, walking, seeing, learning, hearing and speaking.

Documentation

Students requesting disability related assistance must provide documentation establishing the presence of a substantially limited condition(s) and describing its current impact. Conditions affecting major life activities may vary widely, but the following criteria apply to documentation in general:

It must be prepared by a professional who is licensed to practice within a field directly related to, and associated with, the condition. (For example, a medical condition requires documentation from physician.) Additionally it must be provided on official letterhead stationary or the DSS  form and include the following:

Printed name and contact information of the provider

It must reflect the current level of functioning.

Generally, documentation should be no older than three to five years.

Conditions subject to variation may require new documentation every six to twelve months.

The age of the documentation of conditions that are unlikely to change with time may be of less significance, provided the presence of substantial tests will be considered out of date.

All standardized testing must use adult versions of tests. Child-normed tests will be considered out of date.

It must contain information supportive of the student’s request for specific academic supports, auxiliary aids, and accommodations. Guidelines for appropriate documentation of specific disabling conditions are as follows:

Acquired Brain Injury
Attention Deficit/Hyperactivity Disorder
Deaf/Hard of Hearing
Learning Disabilities
Medical Disorders
Mobility/Orthopedic Disorders
Psychiatric Disorders
Visual Disorders
Temporarily Disabling Conditions

Acquired Brain Injury

Included among the relevant diagnoses in this category are any condition caused by surgery, trauma, or cerebral vascular accident (stroke). Limitations of brain injury may be widely diverse and cause limitations to cognition, memory, communication, behavior, motor abilities, speech, speech of processing information, and sensory abilities.

Recommended providers include: physicians, neurologists, neuropsychologists, psychiatrists, and licensed psychologists and/or clinical social workers. Acceptable documentation must include:
Written statement of diagnosis

Brief history of onset ,to include date incurred, area of brain affected, immediate impairment, synopsis of hospitalization and rehabilitation/therapy

Information specifying current level of intellectual functioning, to include cognitive and achievement measures used and standardizes scores

Information specifying substantially limited residual physical effects

Information specifying current medications prescribed as a result of the injury, to include side effects and possible impact on student academic performance

Summary statement of functional limitations, to include major life activities affected, and the degree of functional impairment

Attention Deficit/Hyperactivity Disorder

It is important to note that a diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD) does not necessarily constitute a disability. The degree of impairment must be significant enough to substantially limit one or more major life activities.

Recommended professionals include: psychologists, neuropsychologists, psychiatrists, and other relatively trained medical doctors. Acceptable documentation must include:

Clearly stated clinical diagnosis of Attention Deficit/Hyperactivity Disorder (Predominantly Inattentive Type, Predominantly Hyperactive- Impulsive Type, or Combined Type), based on DSM-IV criteria.

The names of the assessment instruments(s) used and the scores (standard scores with percentiles) obtained

Brief client history, including evidence of impairment in childhood; statement about use and impact of medications and therapies; and list of academic interventions and/or accommodations used previously

Statement of the student’s functional limitations based on the diagnosis, specifically in a classroom/education setting

Specific recommendations for academic accommodations with a rationale for each accommodation based on the student’s functional limitations.

Deaf/Hard of Hearing:

Deafness can be defined as the inability to perceive sound or speech. The degree of hearing loss and using American Sign Language (ASL) as the primary language will require the accommodations of interpreters.

Hard of hearing refers to individuals who have hearing loss, who may or may not speak ASL, and who often interact with hearing individuals. For DSS purposes, hard of hearing will simply describe individuals with a degree of hearing loss for which they require classroom accommodation.

Recommended providers include general physicians, otorhinolaryngologists, otologists, audiologists, and speech language pathologists. Acceptable documentation must include:

A written statement of diagnosis and etiology

Specification of assessment procedures and instruments used to make the diagnosis

Current audiogram

Classification of the degree of hearing loss as to mild, moderate, or severe

Information regarding functional limitations and academic impact of the hearing loss

Learning Disabilities

A learning disability is a disorder which affects the manner in which individuals with normal or average intelligence take in, retain, and express information. It is commonly recognized as a significant deficit in one of more of the following areas: oral expression, listening comprehension, written expression, basic reading skills, reading comprehension, mathematical calculation, or problem solving.

Recommended providers include  trained, certified, and licensed clinical psychologists, school psychologists, neuropsychologists, learning disabilities specialist, and other professionals with training and experience relevant to adults and their environment. Acceptable documentation must include:

Clear, specific evidence and identification of a learning disability. Whenever possible, use the DSM-IV to diagnose a learning disability. Documentation that names only “learning styles,” “learning differences” Or “learning difficulties,” will not demonstrate the existence of a disability. Comprehensive testing that addresses at least three of the following:

Aptitude: The Wechsler Adult Intelligence Scale-III (WAIS-III) with subtest scores is the preferred instrument.

Achievement: Current levels of functioning in reading. Mathematics and oral and written language are required. The Wechsler Individual Achievement Test (WAIS-II) and the Woodcock-Jackson III: Tests of Achievement. Standard and extended Batteries are preferred.

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 WAIS-III or the Woodcock-Jackson III Test of Cognitive Ability may be used to address these areas.

Please note that Individualized Education Programs (IEPs) or 504 Plans alone are not sufficient documentation. However, they may provide useful information about services previously provided to the student, and therefore may be submitted with comprehensive report.

Standard scores for all tests administered. Percentiles and grade equivalents alone are not sufficient. In addition to test scores, interpretation of the result in an integrated report is required.

A summary of a comprehensive diagnosis interview, to include a description of the presenting problem, the student’s developmental, educational, family medical, psychosocial, and employment histories as relevant, and discussion of dual diagnosis where indicated.

The rationale for any recommended academic adjustments and/or auxiliary aids, using test data to document the need.

Medical Disorders:

This broad category includes substantially limiting, permanent medical conditions which can range from conditions with narrow, highly localized affects to broad systemic conditions. Additionally, students with these disorders may be prescribed medications that cause severe side effects which further limit the student’s ability to function in an academic environment.

Examples of medical disorders include, but are not limited to, diabetes, Crohn’s Disease, muscular dystrophy, cardiovascular disease, multiple sclerosis, cancer, and systemic lupus erythmatosus.

Recommended providers include general physicians and specialty physicians such as rheumatologist, oncologists, cardiologists, and neurologists. Acceptable documentation must include:

Written statement of diagnosis

Assessment procedures and evaluation instruments used in making the diagnosis
Information regarding symptoms of the disorder

Information regarding functional limitations of the disorder, especially as it will affect the student in an academic environment

Information regarding prescribed medications and possible side effects

Restrictions on activities imposed by the condition

Neurological Disorders:

These are disorders of the central and peripheral nervous systems. Examples include, but are not limited to, multiple sclerosis, Parkinson’s disease, Tourette’s syndrome, cerebral palsy, migraines, and acquired brain injuries.

Recommended providers include neurologists, physiatrists, general physicians, and speech language pathology (with advanced graduate degree). Acceptable documentation must include:
Written statements of diagnosis
Assessment procedures; diagnostic evaluation instruments
Information regarding current symptoms
Information regarding current limitations
Information regarding prescribed  medications and possible side effects
Restrictions on activities imposed by condition
Where learning has been effected, the following
Narrative report of the most recent neuropsychological evaluation

Mobility/Orthopedic Disorders:

These are disorders resulting in mobility limitations of the upper and/or lower body. They may occur as a result of accident, progressive neuromuscular disease, congenital conditions, or repetitive motion stress injuries.

Recommended providers include general physicians, podiatrists, neurologists, rheumatologists, cardiologists, and orthopedic surgeons. Acceptable documentation must include:
Written statement of diagnosis
Diagnosis procedures and results, if applicable
Information regarding current symptoms
Information regarding restrictions, if any
Information regarding functional limitations experienced by the student due to the disorder
Information regarding prescribed medication(s) and possible side effects

Psychiatric Disorders:

This category includes disorders of mood, cognition, stress, and dissociative disorders. Examples of specific diagnosis are: bipolar disorder, generalized anxiety disorder, obsessive compulsive disorder, major depression, and post traumatic stress disorder.

Recommended providers include psychiatrists, clinical psychologists, licensed clinical social workers, and school psychologist. Acceptable documentation must include:
A written statement of diagnosis , to include DSM-current classification Information regarding current symptoms and degree severity

A written statement regarding the current impact/effect of the disorder on the student’s functioning, particularly as pertains to an academic environment.

Information regarding restrictions and/or limitations cause by disorder

Information regarding prescribed medication(s) and possible side effects.

Visual Disorders:

These disorders can be divided into two major categories: blindness and low vision. Blindness is the absence of vision, although there may be light and/or color perception. Low vision is generally defined as a visual acuity, in the better eye and with correction, of 200/70 or less. Conditions affecting vision include, but are not limited to, eye disease, structural abnormalities, color blindness, cataracts, and systemic diseases such as diabetes, strabismus, myopia and loss of visual field.

Recommended providers include ophthalmologists, and physicians.Acceptable documentation must include:
A written statements of diagnosis
Diagnostic procedures and results
Information listing current symptoms and degree of severity
Information regarding functional limitations and possible impact in an academic environment
Information regarding prescribed medication(s) and possible side effects
Information regarding restrictions

Temporarily Disabling Conditions:

This category includes impermanent conditions which cause substantial limitations to one of more major life functions, necessitating that students require temporary assistance for a finite period of time. Temporarily disabling conditions typically occur as a result of surgery, accident, or serious illness.

Recommended providers include physicians, dentists, speech/language pathologists, audiologists, orthopedists, psychiatrists, physical or occupational therapists, and neurologists. Acceptable documentation must include:
Written statement of diagnosis
Diagnosis procedures, to include protocols, and results
Information regarding and listing of current symptoms and degree of severity
Information regarding functional limitations impact with an academic environment
Information regarding prescribed medication(s) and possible side effects
Specific information regarding duration of symptoms, functional limitations, restrictions, and use of medication

For Orthopedic/Mobility Related Conditions:

Is the student ambulatory?
Is the injury weight bearing?
Estimation of distance student is permitted to walk/use crutches
Estimation of duration of above listed restrictions