Disability Services

Documentation Guidelines

All students are asked to provide documentation establishing a substantial limitation in a major life activity in order to (1) establish that the individual is a person with a disability and (2) to determine appropriate accommodations.

All documentation, regardless of source, should contain the following six essential features.

  1. A diagnostic statement identifying the disability, date of the current diagnostic evaluation, and the date of the original diagnosis.
  2. A description of the diagnostic criteria or diagnostic tests used.
  3. A description of how the disability affects one of the major life activities and the current functional impact of the disability.
  4. Treatments, medications, assistive devices/services currently prescribed or in use.
  5. A description of the expected progression or stability of the impact of the disability over time should be included.
  6. Information describing the certification, licensure, and/or the professional training of individuals conducting the evaluation.

Documentation may be required from more than one professional source in order to clearly identify the need for accommodations for individuals with multiple disabilities. The age of the documentation will vary dependent on the type and nature of the disability. This variance occurs because some disability-related needs are static while others change rapidly. Missouri Southern State University (MSSU) prefers documentation within the last two to three years.

Submission of documentation is not the same as the request for services. Request for services and/or accommodations must be initiated by the student once he/she is admitted to MSSU. A school plan such as an Individualized Education Plan (IEP) or a 504 Plan is insufficient documentation.

Detailed suggested guidelines for documentation for each area of disability

3. 01.a Individuals Who are Blind or Experience Low Vision

Ophthalmologists are the primary professionals involved in diagnosis and medical treatment of individuals who are blind or experience low vision. Optometrists provide information regarding measurement of visual acuity as well as tracking and fusion difficulties (including but not limited to: eye movement disorders, inefficiency in using both eyes together, misalignment of the eyes, lazy eye, focusing problems, visual sensory disorders, and motor integration). Fellows of the College of Optometrists in Vision Development may also provide therapy in treating the above optometric conditions. The diagnostician should be an impartial individual who is not a family member of the student.

Recommended documentation includes:
  • A clear statement of vision related disability with supporting numerical description (the age of acceptable documentation is dependent upon the disabling condition, the current status of the student, and the student's request for accommodations).
  • A summary of assessment procedures and evaluation instruments used to make the diagnosis and a summary of evaluation results including standardized scores.
  • Present symptoms that meet the criteria for diagnosis.
  • Medical information relating to the student's needs and the status of the individual's vision (static or changing) and its impact on the demands of the academic program.
  • Narrative or descriptive text providing both quantitative and qualitative information about the student's abilities that might be helpful to understanding the student's profile, including the use of corrective lenses and ongoing visual therapy.
  • Further assessment by an appropriate professional may be required if co-existing disabling conditions are indicated. Appropriate accommodations are collaboratively determined by the student and the Coordinator of Student Disability Services.

3.01.b Individuals who are Deaf or Hard of Hearing

Services are provided to all Deaf and hard of hearing individuals who have a documented unaided bilateral hearing loss of at least 30 decibels. The audiologist who conducts this should be an impartial individual who is not related to the student.

Recommended documentation includes:
  • A clear statement of deafness or hearing loss with a current audiogram (the age of acceptable documentation is dependent upon the disabling condition, the current status of the student, and the student's request for accommodations).
  • A summary of assessment procedures used to make the evaluation and a narrative summary of results.
  • Name, address, phone number and title and/or credentials of audiologist.
  • Further assessment by an appropriate professional may be required if co-existing disabling conditions are indicated. The student and the Coordinator of Student Disability Services collaboratively determine appropriate accommodations.

3.01.c Individuals who have Physical Disabilities and/or Systemic Illness

Physical disabilities and systemic illnesses include, but are not limited to: mobility impairments, multiple sclerosis, cerebral palsy, chemical sensitivities, spinal cord injuries, cancer, aids, muscular dystrophy and spinal bifida. Any physical disability and systemic illnesses are considered to be in the medical domain and require the expertise of a physician, including neurologists, psychiatrists or other medical specialists with experience and expertise in the area for which accommodations are being requested. The diagnostician should be an impartial individual who is not a family member to the student.

Recommended documentation includes:
  • A clear statement of the medical diagnosis of the physical disability or systemic illness.
  • Documentation of eligibility should be current, preferably within the last three years; (the age of acceptable documentation is dependent upon the disabling condition, the current status of the student and the student's request for accommodations).
  • A summary of assessment procedures and evaluation instruments used to make the diagnosis, including evaluation results and standardized scores if applicable.
  • A description of present symptoms that meet the criteria for diagnosis.
  • Medical information relating to the student's needs to include the impact of medication on the student's ability to meet the demands of the postsecondary environment.
  • Further assessment by an appropriate professional may be required if co-existing disabling conditions are indicated. The student and the Coordinator of Student Disability Services collaboratively determine appropriate accommodations.

[link to medical documentation form]

3.01.d Individuals who have Psychiatric/Psychological Disabilities

Psychiatric and psychological disabilities include but are not limited to: depressive disorders, post-traumatic stress disorder, bipolar disorder, and disassociative disorders. A diagnosis by a licensed mental health professional including licensed clinical social workers (LCSW), licensed professional counselor (LPC), psychologists, psychiatrists, neurologists is required and must include the license number. The diagnostician should be an impartial individual who is not a family member of the student.

Recommended documentation includes:

A clear statement of the disability, including the DSM-IV diagnosis and a summary of present symptoms.

Documentation for eligibility should be current, preferably within the last three years; (the age of acceptable documentation is dependent upon the disabling condition, the current status of the student and the student’s request for accommodations).

A summary of assessment procedures and evaluation instruments used to make the diagnosis and a summary of evaluation results, including standardized or percentile scores.

Medical information relating to the student’s needs to include the impact of medication on the student’s ability to meet the demands of the postsecondary environment.

Further assessment by an appropriate professional may be required if other disabling conditions are indicated. The student and the Coordinator of Student Disability Services collaboratively determine appropriate accommodations.

3.01.e Individuals with Head Injury/Traumatic Brain Injury

Head Injury or Traumatic Brain Injury is considered medical or clinical diagnosis. Individuals qualified to render a diagnosis for these disorders are practitioners who have been trained in the assessment of Head Injury or Traumatic Brain Injury. Recommended practitioners may include physicians; neurologists; licensed clinical, rehabilitation, and school psychologists; neuropsychologists and psychiatrists. The diagnostician should be an impartial individual who is not a family member of the student.

Recommended documentation includes:

A clear statement of the head injury or traumatic brain injury and the probable site of lesion.
Documentation for eligibility should be current, preferably within the last three years (the age of acceptable documentation is dependent upon the disabling condition, the current status of the student, and the student’s specific request for accommodations).
A summary of cognitive and achievement measures used and evaluation results including standardized scores or percentiles used to make the diagnosis.
A summary of present residual symptoms that meet the criteria for diagnosis.
Medical information relating to student’s needs to include the impact of medication on the student’s ability to meet the demands of the postsecondary environment.
Further assessment by an appropriate professional may be required if co-existing disabling conditions are indicated. The student and Coordinator of Student Disability Services collaboratively determine appropriate accommodations.

3.01.f Individuals who have Attention Deficit Hyperactivity Disorder

Although the more generic term Attention Deficit Disorder (ADD) is frequently used, the official nomenclature used in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), Attention Deficit/Hyperactivity Disorder (ADHD) will be used in this document.

All documentation should have the following four features:

1. Documentation must be current.

  • Since accommodations are based on the current impact of the disability, documentation must be current, preferably within the last three years.

2. The diagnostician must be qualified to diagnose.

  • Professionals rendering a diagnosis of ADHD must have comprehensive training in differential diagnosis and direct experience working with adolescents and adults with ADHD. The following professionals are considered qualified to evaluate and diagnosis ADHD: clinical psychologists, neuropsychologists, psychiatrists, and other qualified medical doctors.

3. A comprehensive assessment should be performed.

The following criteria are based on guideline from the Consortium on ADHD Documentation*:

  • Evidence of Early Impairment – ADHD is, by definition, first exhibited in childhood and manifests itself in more than one setting, historical and academic information must be gathered by the evaluator.
  • Evidence of Current Impairment – Diagnostic assessment should consist of more than a self-report; history of attentional symptoms, including evidence of on going impulsive/hyperactive or inattentive behavior that has significantly impaired functioning over time is critical to the diagnosis of ADHD.
  • Alternative Diagnosis and/or Explanations – Diagnostic assessment should examine the possibility of co-existing diagnosis. This process should explore possible alternative diagnosis including medical and psychiatric disorders as well as educational and cultural factors, which impact the individual and may result in behaviors mimicking ADHD.
  • Diagnostic Battery – Neuropsychological or psycho educational assessment is critical in determining the current impact of the disorder on the individual’s ability to function in a variety of settings. Assessment must include standardized measures for inattention, hyperactivity and impulsivity as delineated in the DSM-IV.

4. Diagnostic Report & Summary

The diagnostic report must be a comprehensive interpretive summary synthesizing the evaluator’s judgement for the diagnosis of ADHD. The report must include:

  • All quantitative information in standard scores and/or percentiles; all relevant developmental, familial, medical, medication, psychosocial, behavioral and academic information;
  • A specific diagnosis of ADHD based on the DSM-IV diagnostic criteria. In clear, direct language, the report must identify the substantial limitation of a major life function presented by ADHD;
  • Official letterhead with names, titles, professional credentials, addresses, and phone/fax numbers of the evaluator as well as the date(s) of testing.
  • Further assessment by an appropriate professional may be required if co-existing disabling conditions are indicated. The student and the Coordinator of Student Disability Services collaboratively determine appropriate accommodations.
  • * Policy Statement for Documentation of Attention-Deficit/Hyperactivity Disorder in Adolescents and Adults by Educational Testing Service (1998)

3.01.g Individuals with Learning Disabilities

The following guidelines for the documentation of a learning disability are based on the Guidelines for Documentation of a Learning Disability in Adolescents and Adults* and adopted by Missouri Southern State College.

The documentation of a learning disability is based on the diagnostic assessment. Below are the features that should be included in a psychological and educational assessment. In addition, the diagnostic assessment should have been completed within the past three years in order to reflect current functioning.

Diagnostic Interview – an evaluation report should include the summary of a comprehensive diagnostic interview. Relevant information regarding the student’s academic history and learning processes in elementary, secondary and postsecondary education should be investigated. The diagnostician, suing professional judgement as to which areas are relevant, should conduct a diagnostic interview which may include: a description of the presenting problem(s); developmental, medical, psycho-social and employment histories; family history (including primary language of the home and the student’s current level of English fluency); and a discussion of dual diagnosis where indicated.

Assessment – Evidence of a substantial limitation to learning or other major life activity must be provided.

Testing must include at least one assessment from each of the following areas:

Aptitude
  • Weschler Adult Intelligence Scale-Revised (WAIS-R) (Must include Full Scale IQ, Verbal IQ, Performance IQ, and all subtest scores)
  • Woodcock Johnson Psycho educational Battery-Revised: Tests of Cognitive Ability (must include either tests 1-7 or 1-14)
  • Standford-Binet Intelligence Scale
  • Kaufman Adolescent and Adult Intelligence Test
Achievement
Reading
  • Woodcock Johnson Pychoeducational Battery-Revised: Tests of Achievement
  • Scholastic Abilities Test for Adults (SATA)
  • Stanford Test of Academic Skills
  • Wechsler Individual Achievement Test (WIAT)
  • Nelson Denny Reading Skills Test
  • Woodcock Reading Mastery Tests Revised
Mathematics
  • Woodcock Johnson Psycho educational Battery-Revised: Tests of Achievement
  • Scholastic Abilities Test for Adults (SATA)
  • Stanford Test of Academic Skills
  • Wechsler Individual Achievement Test (WIAT)
  • Test of Mathematical Abilities (TOMA)
  • Stanford Diagnostic Mathematics Test
Written Language
  • Woodcock Johnson Psycho educational Battery-Revised: Tests of Achievement
  • Scholastic Abilities Test for Adults (SATA)
  • Stanford Test of Academic Skills
  • Wechsler Individual Achievement Test (WIAT)
  • Test of Written Language

****NOTE: The above list is not intended to be exhaustive or to limit assessment in other areas that might be pertinent to the individual’s needs.

Specific Diagnosis

The report must include a clear statement of the learning disability, and the rationale for this diagnosis as supported by the current diagnostic battery. Individual “learning styles,” “learning differences,” “learning deficits,” and “learning disorders” do not, in and of themselves, constitute a disability.

4. Test Scores

Standard scores and/or percentiles should be provided for all normed measures. Grade equivalents are not useful unless standard scores and/or percentiles are also included. The data should logically reflect a substantial limitation to learning for which the student is requesting an accommodation. The particular profile of the student’s strengths and weaknesses must be shown to relate functional limitations that may necessitate accommodations.

The test used should be reliable, valid and standardized for use with an adolescent/adult population. The test findings should document both the nature and severity of the learning disability. Informal inventories surveys and direct observation by a qualified professional may be used in tandem with formal tests in order to further develop clinical hypothesis.

5. Clinical Summary

Assessment instruments and the data they provide do not diagnose; rather, they provide important elements that must be integrated by the evaluator with background information, observations of the client during the testing situation, and the current context. It is essential, therefore, that professional judgement be utilized in the development of a clinical summary. The clinical summary should include:

Demonstrate that the evaluator ruled out alternative explanations for the academic problems

That patterns in the individual’s cognitive abilities, achievement, and information processing reflect the presence of a learning disability.

The substantial limitation to a major life activity and the degree of impact.

6. The Diagnostician

Professionals conducting assessments and rendering diagnosis of specific learning disabilities must be qualified to do so. Trained and certified and/or licensed psychologists, neuropsychologists, learning disability specialists, and educational therapists are considered qualified to evaluate specific learning disabilities. Diagnostic reports should include the names, titles, professional credentials, addresses, and phone numbers of the evaluators as well as the date(s) of testing.

* Guidelines for Documentation of a Learning Disability in Adolescents and Adults

Association of Higher Education and Disability (1997)

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