Documentation Guidelines

I. A qualified professional must conduct the evaluation

Name, title, professional credentials, licensure/certification information, and location of practice must be included on any reports submitted. Evaluators must have professional training in, and experience with, evaluating learning disabilities in adolescents and/or adults. Evaluations performed by members of the student’s family are not acceptable. All reports must be on letterhead.

 II. Documentation must be current.

Reports should reflect the current functional limitations of the student.  In general, evaluations conducted in the last three years will be considered timely, however, older documentation may suffice if diagnosis and impact are consistent. *Please note many testing agencies will not accept documentation greater than three years old. Documentation should describe the current impact of the diagnosed condition in the academic and clinical domains. If able, the evaluator should make recommendations appropriate to a professional health science program setting.

 III. Documentation must be comprehensive.

Reports should include a full history of the student (medical, developmental, academic, familial), and indicate any evidence of early impairment, even if not formally diagnosed in childhood or early adolescence. Reports should indicate evidence of current impairment, including the results of a diagnostic interview and a battery of psychoeducational tests designed to identify learning disabilities. Minimally, testing must include a) assessment of cognitive ability/intellectual functioning, b) measurement of academic achievement, c) instruments that measure various domains of information processing, d) other instruments to help confirm or rule out the diagnosis of learning disability.
A specific diagnosis must be included if indicated. If the evaluation does not clearly indicate the existence of a learning disability, the examiner must state that fact. All test scores should be included, along with an interpretation of each and a summary.

 Documentation should rule out alternative explanations for learning problems (i.e. difficulties that are motivational, emotional, attentional, or related to limited fluency in the English language.)
Documentation should address any coexisting disorders or suspected coexisting disorders.
Documentation must indicate whether or not the evaluator believes the diagnosed condition rises to the level of a disability as defined in the Americans with Disabilities Act (ADA). A clear indication of the student’s functional limitations must be included. Documentation should tie recommendations for accommodation directly to the designated functional limitations. A rationale, explaining why each recommendation for accommodation is appropriate, should be given.

I. A qualified professional must conduct the evaluation.

Name, title, professional credentials, licensure/certification information, and location of practice must be included on any reports submitted. Evaluators must have training in, and experience with, the differential diagnosis of psychiatric disorders in adolescents and/or adults. All reports must be signed by the evaluator and should be typed on letterhead.

 II. Documentation must be current.

Reports should, in general, be based on evaluations performed within six months.If a report is older than six months, and the student has remained in clinical contact with his or her evaluator, that professional may supplement the original report with a letter (on letterhead) describing any and all changes since the previous report. [The supplement would be in lieu of another complete report.] Documentation, including any supplements, should describe the current impact of the diagnosed condition(s). Documentation should describe any currently mitigating factors, such as medication or other treatment that further impact the students functioning, contributing to functional limitation (i.e., cognitive fogging or slowing due to side effects of medication). Documentation should make recommendations appropriate to a professional school environment.

 III. Documentation must be comprehensive.

Reports should include a brief history of the student’s disorder. A specific diagnosis, or more than one, must be included. Reports must indicate that DSM-IV criteria have been met for each condition. Other potential diagnoses must be ruled out in the report. Documentation must indicate whether or not the evaluator believes the diagnosed condition(s) rise(s) to the level of a disability as defined in the Americans with Disabilities Act (ADA). There must be a clear indication of the individual student’s functional limitations, in a professional school environment and across other life domains. Documentation should include recommendations for accommodations that are directly related to the functional limitations. A rationale, explaining why each recommendation for accommodation is appropriate, should be given. A clinical summary is helpful.

I. A qualified professional must conduct the evaluation.

Name, title, professional credentials, licensure/certification information, and location of practice must be included on any reports submitted. Evaluators must have professional training in, and experience with evaluating the diagnosis of like or similar conditions in adult populations. Evaluations performed by members of the student’s family are not acceptable. All reports must be signed by the primary evaluator and presented on letterhead.

 II. Documentation must be current.

Reports should be based on evaluations performed within a reasonable time frame, depending on the degree of change associated with the diagnosed condition(s). Generally, a reasonable time frame is within three years but may vary depending on the disability.Reports should accurately describe the current impact of the diagnosed condition and should indicate the currently anticipated course of the condition.

III. Documentation must be comprehensive.

Reports should include both a description of and evidence of impairment. They should briefly describe any current treatment plan. A specific diagnosis (or more than one) must be included. Documentation should address any coexisting conditions, suspected coexisting conditions, or other confounding factors. Documentation must indicate whether or not the diagnosed condition(s) rises to the level of a disability as defined by the Americans with Disabilities Act (ADA). This professional opinion should then be explained. There must be a clear indication of the individual student’s functional limitations. Documentation should include recommendations for accommodations that are directly related to the functional limitations (and relevant to a professional school environment if possible.) A rationale, explaining why each recommendation for accommodation is appropriate, should be provided.