Documentation Guidelines For ADD/ADHD Documentation

Students with ADD/ADHD who are requesting support services from the Office of Services for Students with Disabilities at West Chester University are required to submit documentation to verify eligibility under the Americans with Disabilities Act of 1990. The following guidelines are provided to ensure that the documentation is complete and appropriate.

1. The documentation must include a diagnosis of ADD/ADHD and the rationale for this diagnosis (e.g., DSM IV criteria).
2. The diagnosis must be a medical diagnosis or part of a comprehensive clinical evaluation.
3. The evaluation must have been completed within the previous three years.
4. The documentation must include the following information:
• The name(s) of the assessment instrument(s) used (aptitude, achievement, information processing and behavioral checklists).
• Quantitative and qualitative information that supports the diagnosis.
• The severity of the condition.
• The areas of educational impact.
• Recommendations for prescriptive treatments, environmental management and reasonable accommodations.
• Notations for medications prescribed, if any, and monitoring arrangements.
• Additional observations or recommendations that would assist in meeting the individual needs of the student.
• The names, titles, addresses, telephone and fax numbers of the evaluators as well as the date(s) of testing.

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Documentation Guidelines For Learning Disabilities

Students with learning disabilities who are requesting support services from the Office of Services for Students with Disabilities (OSSD) at West Chester University are required to submit documentation to verify eligibility under the Americans with Disabilities Act of 1990. The following guidelines are provided to ensure that the documentation is complete and appropriate.

1. The documentation must include a diagnosis of LD and the rationale for this diagnosis.
2. The diagnosis should be made by a licensed or certified professional and/or someone trained in psycho-educational assessment.
3. The evaluation information should be current and relevant to the setting. (Although LD is a life long condition, circumstances change and the need for specific accommodations and/or services at the college level must be made at the time of matriculation. Further, students should be fully informed of their disability, strengths and weaknesses so they can make a reasonable accommodation request and be self advocates.)
4. The assessment battery must include a cognitive evaluation (WAIS-R or WJ-R) and achievement battery and the following information.
• The name(s) of the assessment instrument(s) used.
• Quantitative and qualitative information that supports the diagnosis.
• The severity of the condition(s).
• The areas of educational impact.
• Additional observations or recommendations that would assist in meeting the individual needs of the student.
• The names, titles, addresses, telephone and fax numbers of the evaluators as well as the date(s) of testing.

In addition, specific recommendations for accommodations (with explanation of how the need is substantiated through testing) will be helpful to WCU personnel in assigning appropriate accommodations for the student. This can be in the form of a Statement of Performance or other document.

In and of themselves, documents such as an SOP, IEP, or 504 plans are not sufficient to qualify for accommodations at the college level.

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Documentation For Physical/Mobility/Chronic Health Disabilities

What are Physical/Mobility/Chronic Health Disabilities?

Known as mobility, systemic, or a disease-related disability, these result from congenital conditions, accidents, or progressive neuromuscular diseases. These disabilities include, but are not limited to conditions such as spinal cord injury (paraplegia or quadriplegia), cerebral palsy, lupus, spinal bifida, chemical sensitivities, amputation, muscular dystrophy, cardiac conditions, cystic fibrosis, paralysis, polio/post polio, cancer and stroke. Functional limitations and abilities vary greatly even within one type of disability. Accommodations vary greatly and are best determined on a case-by-case basis.

What are Common Types of Mobility/Physical/Chronic Health Impairments?

• AIDS/HIV
• Arthritis
• Asthma
• Cancer
• Cerebral Palsy (CP):Non-progressive motor disorders of the central nervous system.
• Chronic Pain
• Diabetes Mellitus
• Epilepsy/Seizure Disorder
• Epstein Barr Virus/Chronic Fatigue
• Hemophilia
• Lupus
• Lyme's Disease
• Motor Neuron Diseases: may include symptoms such as pain, numbness, weakness, loss of upper and lower motor functions, and problems in breathing.
• Multiple Sclerosis: may limit gross motor functions and/or fine motor activity.
• Muscular Dystrophy
• Renal-Kidney Disease
• Respiratory Disorders
• Sickle Cell Anemia
• Stroke
• Tourette's Syndrome

What are the Documentation Guidelines?

Assessment, and any resulting diagnosis, should consist of and be based on a comprehensive assessment battery that does not rely on any one test or subtest. Both aptitude and academic achievement must be evaluated and included in the assessment report.

The following guidelines are provided in the interest of assuring that the service provider, in collaboration with the student, determines an appropriate diagnosis and establish reasonable accommodations. Documentation serves as a foundation that legitimizes a student's request for appropriate accommodations.

Recommended documentation includes:

• Diagnosis (clear statement of the medical diagnosis of the condition).
• Date of the original diagnosis.
• Date of the most recent evaluation (usually within a year, the age of acceptable documentation is dependent upon the disabling condition, current status, and the student's request for accommodations).
• Diagnostic criteria/assessment procedures used to make the diagnosis;
• Description of the present symptoms.
• Description of current impact of the condition (including impact of medication).
• Treatments/medications/devices or services currently prescribed.
• Expected duration, stability, or progression of the condition.
• Functional impact or limitation of the disability on learning or other major life activity.
• Medical information with signature of appropriate physician on letterhead stationery. Professionals conducting diagnostic studies and rendering diagnosis should be qualified to do so. Generally, professionals recognized as qualified to make the diagnosis are physicians and nurse practitioners in conjunction with specialists experienced in working with the particular condition, such as physical therapists, occupational therapists, and rehabilitative specialists who are licensed and certified. The diagnostician should be impartial and not be a family member.

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Documentation Guidelines For Psychiatric Disabilities

Terms

Psychiatric disabilities: Comprise a range of conditions characterized by emotional, cognitive, and/or behavioral dysfunction. A diagnosis of a disorder does not, in and of itself, meet the definition of a disability necessitating reasonable accommodations under the ADA or Section 504 of the Rehabilitation Act of 1973.

Major life activity: Examples of major life activities include walking, sitting, standing, seeing, hearing, speaking, breathing, learning, working, caring for oneself, and other similar activities.

Functional limitation: A substantial impairment in the individual's ability to function in the condition, manner, or duration of a required major life activity.

Documentation Requirements:

A Qualified Professional Must Conduct the Evaluation.

The assessment must be administered by a trained, qualified, and licensed professional, who has had direct experience with adolescents and adults with psychiatric disorders. A qualified professional may include but is not limited to a medical doctor, psychologist, or student clinician who is being supervised by a professional. The evaluator's name, title and professional credentials and affiliation should be provided. The professional completing the evaluation should not be a family member. All reports should be on letterhead, typed, dated, signed, and otherwise legible.

Documentation Must Be Current

Reasonable accommodations are based on the current (i.e. within the last six months) impact of the disability on academic performance. A diagnostic evaluation should be relevant to the student's learning environment and show the student's current level of functioning. If documentation does not address the individual's current level of functioning, a re-evaluation may be required.

Documentation Must Include a Specific Diagnosis

The report must be comprehensive and include a specific diagnosis based on the DSM-IV-TR diagnostic criteria. It is recommended that the clinician report the diagnostic criteria used to support the diagnosis. The diagnostician should use direct language in the diagnosis, avoiding the use of terms such as "suggests" "appears" or "is indicative of".

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Documentation Guidelines For Sensory Impairments

Hearing Impairments and Deafness

Students who are deaf or hard-of-hearing must provide documentation consisting of:

• An audio logical evaluation and/or audiogram;
• An interpretation of the functional implications of the diagnostic data.

Visual Impairments and Blindness

Students requesting accommodations on the basis of low vision or blindness must provide documentation consisting of:

• An ocular assessment or evaluation from an ophthalmologist, or a low-vision evaluation of residual visual function, where appropriate;
• An assessment of functionally limiting manifestations of the disabling condition.

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