Documentation Requirements

Documentation Requirements

for disorders other than Specific Learning Disabilities, please download and submit the Disability Verification Form to the appropriate licensed medical professional for completion. Usually, this will be an M.D. or  D.O who specializes in the diagnosis and treatment of the medical condition or a licensed psychologist in the case of neurocognitive or psychological diagnoses.  Documentation must be completed and signed by the licensed medical professional. The documentation may not be completed or signed by a relative of the student who is seeking accommodations. If documentation is deemed to be incomplete, not recent enough, from an inappropriate provider or otherwise inadequate,  provisional and temporary accommodations may be provided for a maximum of one semester. Documentation equivalent to the Disability Verification Form or a Psychological Evaluation Report are also acceptable if is includes the following elements and testing results:  

  • Documentation must be on letterhead, include a diagnosis, description of impacts and impairments, recommendations and be signed by an appropriate medical professional
  • Allergies must be documented by an allergist with appropriate test results indicating the specific allergens, the severity of each allergy and treatment plan.  
  • Gastrointestinal disorders must be documented by a gastroenterologist 
  • Autoimmune disorders must be documented by a rheumatologist or other appropriate specialist 
  • Orthopedic disorders must be documented by an orthopedic doctor
  • Neurological disorders must be documented by a neurologist 
  • Learning Disabilities and other cognitive impairments must be documented by a comprehensive evaluation report that includes appropriate test data
  • Cardiac disorders must be documented by cardiologist 
  • Visual impairments must be documented by a licensed ophthalmologist or optometrist and include visual acuity with best correction in both eyes, visual field, and a description of functional vision for both eyes 
  • Hearing impairments must be documented by a licensed audiologist and include aided and unaided hearing, soundfield and speech discrimination test results.  All documentation should include functional limitations and recommendations for accommodation. 


Disability Verification Form for Undergraduates

 

I. A qualified professional must conduct the evaluation

 

  1. The name, title, and professional credentials of the evaluator-including information about license or certification, as well as the area of specialization and state or province in which the individual practices should be clearly stated in the documentation. Comprehensive training and relevant experience with the applicable medical condition are essential.
  2. This documentation should be completed by an appropriate licensed medical practitioner, who has direct knowledge of you and your disability. For example, documentation for a visual impairment would be completed by an ophthalmologist and a hearing impairment by an audiologist. Learning Disabilities must be documented by a comprehensive psychoeducational evaluation completed by a licensed psychologist. These examples are meant to be illustrative and not comprehensive.
  3. All letters or reports must be on letterhead, typed, dated, and bear the signature of the evaluator. Originals can be returned to student, if requested.
  4. Competence in working with culturally and linguistically diverse populations is also essential. It is of utmost importance that evaluators are sensitive and respectful of cultural and linguistic differences.

II. Documentation must be current

  1. Documentation must be current. Because the provision of reasonable accommodations and services is based upon the Disability Services Coordinator’s assessment of the current impact of the disability on academic performance, it is in a student’s best interest to provide recent and appropriate documentation.
  2. It is important to recognize that accommodation needs can change over time and are not always identified through the initial diagnostic process. Conversely, a prior history of accommodations does not, in and of itself, warrant the provision of a similar accommodation.
  3. Due to the type and stability of a disability, the appropriate time period varies. As a general rule, for diagnoses other than learning disabilities, documentation should be dated within 1-2 years. Psychoeducational reports are required when documenting learning disabilities and should be dated after age 13. If documentation is inadequate in scope, content or recency or does not address the individual’s current level of functioning and need for accommodations, an addendum or re-evaluation may be required.

III. Documentation necessary to substantiate the diagnosis must be comprehensive

  1. To properly document a need for accommodations under ADA/504 for individuals with medical conditions, clinicians should use the appropriate medical testing.
  2. The data must logically reflect a substantial impairment for which the student is requesting accommodation.
  3. The particular profile of the student’s strengths and weaknesses must be shown to relate to functional limitations that may necessitate accommodations.
  4. The testing instruments must be reliable, valid, and standardized for use with an adolescent/adult population.
  5. Informal inventories, surveys, self-reports, and direct observation by a qualified professional may be used in tandem with formal tests in order to further develop a clinical hypothesis.
  6. If the medical condition manifests itself in reading, math or writing and is not related to low vision the appropriate testing, as well as qualified professional conducting the evaluation, should be the same as for a learning disability.

IV. Documentation must include a specific diagnosis

  1. The letter or report must include a specific diagnosis of the disability. The diagnostician should use direct language in the diagnosis of the disability.
  2. The following should be addressed:
    1. Date and method of diagnosis, including any test results and analysis, as well as, current medical treatment, medications or technology used, and a brief chronological history of relevant services, surgeries or treatments.
    2. How the medical condition affects one or more major life activities. This is the essential criterion necessary to have the medical condition considered a disability. Although a medical condition may be considered a disability in one patient, this does not imply that the impact will be the same for all persons with the condition.
    3. What are the functional limitations and how are they related to the requested accommodation?
    4. The future prognosis of the medical condition. Is the condition temporary or permanent, progressive or stable? If temporary, what is the severity and expected duration of the impairment.
  3. Categories of disabilities include:
    1. Hearing Impairment: A hearing loss of 30 decibels or greater, pure tone average of 500, 1000, 2000 Hz, ANSI, unaided, in the better ear. Examples include, but are not limited to, conductive hearing impairment or deafness, sensorineural hearing impairment or deafness, high or low tone hearing loss or deafness, and acoustic trauma hearing loss or deafness. Documentation should include both unaided and aided audiogram results. For a diagnosis of Central Auditory Processing Disorder, see Learning Disabilities documentation requirements below. 
    2. Physical Impairment: Musculoskeletal and connective tissue disorders, neuromuscular disorders, and physically disabling conditions that may require adaptation to one’s school environment or curriculum. Examples include, but are not limited to, cerebral palsy, absence of some body member, clubfoot, nerve damage to the hand and arm, cardiovascular aneurysm, head injury and spinal cord injury, arthritis and poliomyelitis, multiple sclerosis, Parkinson’s disease, congenital malformation of brain cellular tissue, and physical disorders pertaining to muscles and nerves, usually as a result of disease or birth defect, including but not limited to muscular dystrophy and congenital muscle disorders. General medical conditions including certain cardiovascular and circulatory conditions, blood serum disorders, epilepsy, allergies and respiratory disorders.
    3. Speech Disability: Disorders of articulation, fluency or voice that interfere with communication, pre-academic or academic learning, vocational training, or social adjustment. Examples include, but are not limited to, cleft lip and or palate with speech impairment, stammering, stuttering, laryngectomy and aphasia.
    4. Visual Impairment: Disorders in the structure and function of the eye as manifested by at least one of the following: (a) visual acuity of 20/70 or less in the better eye after the best possible correction; (b) a peripheral field so constricted that it affects one’s ability to function in an educational setting; or (c) a progressive loss of vision that may affect one’s ability to function in an academic setting. Examples include, but are not limited to, cataracts, glaucoma, nystagmus, retinal detachment, retinitis pigmentosa, and strabismus.
    5. Psychological Disabilities: Cognitive and psychiatric disabilities including mood disorders, bipolar disorders, attention deficit disorders, eating disorders, psychoses, and other diagnoses found in the Diagnostic and Statistical Manual (DSM).
    6. Learning Disabilities: Neurologically based disabilities that are manifested by average or above average intelligence combined with a significant impairment in reading, writing, math or language which are due to an identified impairment in one or more basic neurocognitive processes. An IEP or 504 plan alone are not considered adequate documentation to support accommodations for a learning disability. A Psychological Evaluation Report must be submitted as documentation of a learning disability.  The scope and recency of the report will depend upon the history of accommodation.

V. Each accommodation recommended by the evaluator must include a rationale

  1. The evaluator must describe the impact of the diagnosed disability on a specific major life activity as well as the degree of impact on the individual. The diagnostic report must include specific recommendations for accommodations that the post-secondary institution can reasonably provide.
  2. A detailed explanation as to why each accommodation is recommended must be provided and should be correlated with specific functional limitations determined through interview, observation, and/or testing.
  3. A school plan such as an Individualized Education Program (IEP), Summary of Performance or a 504 plan is insufficient documentation in and of itself but can be included as part of a more comprehensive evaluative report. If possible, the criteria for placement in a specialized program should be included.
  4. The documentation should include any record of prior accommodations or auxiliary aids, including information about specific conditions under which the accommodations were used, and whether or not they benefited the individual.
  5. If no prior accommodations were provided, the evaluator must include an explanation of why no accommodations were needed in the past and why accommodations are needed at this time.

VI. An interpretative summary must be provided

  1. A diagnostic summary based on a comprehensive evaluative process is a necessary component of the report. Assessment instruments and the data they provided 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.
  2. To document a need for accommodations under 504/ADA for individuals with medical conditions, clinicians should consider certain key issues. These issues involve establishing the credibility of the diagnosis, the severity of the impairment, and the suitability of the accommodations for the tasks at hand.
  3. The following should be addressed:
    1. How the medical condition affects the patient in an academic setting. This would include any necessary academic accommodations required as a direct result of the disability.
    2. How these academic accommodations would mitigate the effects of the disability.

VII. Documentation serves as the basis for determining eligibility for accommodations.

  1. If the requested accommodation is not clearly identified in the diagnostic report, the ACCESS Coordinator may request additional documentation for clarification.
  2. The ACCESS Coordinator will make the final determination as to whether  the recommended accommodations are appropriate and reasonable. This determination is based upon the documentation provided and legal guidelines. Alternative accommodations that provide equal access may be offered.
  3. If a student believes that the reasonable accommodations required by law are not provided after documentation requirements have been met and university procedures have been complied with, an appeal may be made through the University’s Disability Grievance Policies as outlined in the Mercer Student Handbook and found on the ACCESS and Accommodation website.