Documentation Guidelines
Overview
In accordance with the Rehabilitation Act of 1973 (Section 504) and The Americans with Disabilities Act of 1990 (ADA), the Office of Student Disability Services coordinates support services and determines “reasonable academic adjustments” based on demonstrated needs of the student as supported by documentation from the medical provider. Documentation must be appropriate and current (within 3 years). The documentation must provide a clear connection between the disability and how the major life activity (learning) is substantially limited. The Office of SDS is responsible for promoting access to facilities and programs, ensuring equal educational opportunities, acting as an informational and referral source and serving as a liaison between faculty and student. However, the University is not required by law to change the “fundamental nature or essential curricular components of its programs in order to accommodate the needs of disabled students.”
Individualized Education Plans (IEP) or 504 Accommodation Plans from high school alone are not considered adequate documentation, although submission of such documents can serve as supplementary documentation and aid in the determination of appropriate accommodations. Prior receipt of accommodations (e.g. high school) does not automatically guarantee receipt of the same accommodations at the University level as accommodations for high school and postsecondary education may differ.
Disclosure of a disability to the Office of SDS is the student's responsibility. The Office of SDS cannot act on verbal or written statements by a parent, counselor or teacher. If specific accommodations are needed, the student must notify the Director of the Office of SDS, provide documentation and set up an appointment to meet and discuss what accommodations are appropriate.
Criteria Required for Disability Documentation
The dimensions of good documentation discussed below are suggested as a best practice approach for defining complete documentation that both establishes the individual as a person with a disability and provides a rationale for granting reasonable accommodations. These guidelines are developed to assist prospective students in working with treating/diagnosing professionals in preparation for information needed to evaluate the request for accommodations. By identifying the essential dimensions of documentation, institutions allow for flexibility in accepting documentation from the full range of theoretical and clinical perspectives. This approach will enhance consistency and provide stakeholders (students, prospective students, parents and professionals) with the information needed to assist students in establishing eligibility for services and receiving appropriate accommodations.
Documentation requirements are adapted from guidelines developed by AHEAD (Association of Higher Education and Disability) and users of this document may wish to review AHEAD’s best practice information found at www.ahead.org.
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Quality documentation is provided by a licensed or otherwise properly credentialed professional who has undergone appropriate and comprehensive training, has relevant experience and has no personal relationship with the individual being evaluated. A good match between the credentials of the individual making the diagnosis and the condition being reported is expected.
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Quality documentation includes a clear diagnostic statement that describes how the condition was diagnosed, provides information on the functional impact and details the typical progression or prognosis of the condition. While diagnostic codes from the Diagnostic Statistical Manual of the American Psychiatric Association (DSM) are helpful in providing this information, a full clinical description will also convey the necessary information.
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Quality documentation includes a description of the diagnostic criteria, evaluation methods, procedures, tests and dates of administration, as well as a clinical narrative, observation and specific results. Where appropriate, having both summary data and specific test scores (with the norming population identified) within the report is recommended.
Diagnostic methods that are congruent with the particular disability and current professional practices in the field are recommended. Methods may include formal instruments, medical examinations, structured interview protocols, performance observations and unstructured interviews. If results from informal, non-standardized or less common methods of evaluation are reported, an explanation of their role and significance in the diagnostic process will strengthen their value in providing useful information.
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Information on how the disabling condition(s) currently impacts the individual provides useful information for both establishing a disability and identifying possible accommodations. A combination of the results of formal evaluation procedures, clinical narrative and the individual’s self-report is the most comprehensive approach to fully documenting impact. The best quality documentation is thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition(s).
While relatively recent documentation is recommended in most circumstances, common sense and discretion in accepting older documentation of conditions that are permanent or non-varying is recommended. Likewise, changing conditions and/or changes in how the condition impacts the individual brought on by growth and development may warrant more frequent updates in order to provide an accurate picture. It is important to remember that documentation is not time-bound; the need for recent documentation depends on the facts and circumstances of the individual’s condition.
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It is helpful when documentation provides information on expected changes in the functional impact of the disability over time and context. Information on the cyclical or episodic nature of the disability and known or suspected environmental triggers to episodes provides opportunities to anticipate and plan for varying functional impacts. If the condition is not stable, information on interventions (including the individual’s own strategies) for exacerbations and recommended timelines for re-evaluation are most helpful.
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The most comprehensive documentation will include a description of both current and past medications, auxiliary aids, assistive devices, support services and accommodations, including their effectiveness in ameliorating functional impacts of the disability. A discussion of any significant side effects from current medications or services that may impact physical, perceptual, behavioral or cognitive performance is helpful when included in the report. While accommodations provided in another setting are not binding on the current institution, they may provide insight in making current decisions.
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Recommendations from medical providers with a history of working with the individual provide valuable information for review and the planning process. It is most helpful when recommended accommodations and strategies are logically related to functional limitations. If connections are not obvious, a clear explanation of their relationship can be useful in decision-making. While the post-secondary institution has no obligation to provide or adopt recommendations made by outside entities, those that are congruent with the programs, services, and benefits offered by the college or program may be appropriate. When recommendations go beyond equitable and inclusive services and benefits, they may still be useful in suggesting alternative accommodations and/or services.
Medical Conditions
Conditions that are treated by an M.D. or specialist are considered to be medical. Some conditions are chronic and unchanging (e.g. neuropathy), some are temporary (e.g., broken bones) and some are in a state of flux (e.g., Lupus). These types of conditions require a current statement by a licensed clinician.
Mobility Impairments
Mobility impairments may be chronic or temporary. Students with temporary mobility constraints should contact the Office of Student Disability Services to discuss assistance while a student is incapacitated. A note from the treating M.D. is needed for temporary conditions. For chronic impairments, documentation from the treating physician is necessary only once at the time of registration with the Office of Student Disability Services.
Auditory and Visual Impairments
Students with chronic and unchanging auditory or visual impairments (e.g., deafness, blindness) must submit current documentation (within 6 months of matriculation) from their treating physicians, including any certifications of deafness or blindness (if applicable), psychoeducation testing or neuropsychological testing (if performed) within 3 years of the matriculation date of the student. Students who have conditions such as these should register with the Office of Student Disability Services early, as their needs will require a team approach to coordinate services in and out of the classroom. Documentation for chronic auditory or visual impairments is submitted to the Office of SDS once during a student’s academic career.
Mental Health Conditions
Mental health conditions occasionally require academic accommodations. In order for a mental health condition to rise to the level of a disability, the diagnosis must be older than 6 months, the condition must be impairing the student’s ability to learn or perform the necessary components of learning and must be consistent with the latest version of the DSM available to the community. Documentation for mental health disabilities must be in accordance with the criteria listed above and be signed by the clinician within 6 months of matriculation and updated annually at the start of the academic year (fall semester).
*Please note: Beginning with the revisions to the Americans with Disabilities Act (ADA) in 2008, test anxiety is no longer considered a disability under federal law. If you are applying for academic accommodations related to anxiety, your assessor must diagnose you with an anxiety disorder that is more general (such as Generalized Anxiety Disorder) and must include examples of areas of your life where anxiety creates a disability beyond the testing situation.
Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Hyperactivity Disorder, (ADHD), is a life-long condition that typically presents in prior school settings. ADHD may impact a person’s learning in many different ways and has several different presentations for students. Students with a diagnosis of ADHD or ADD should submit a letter as specified above along with a psycho-educational or neuropsychological evaluation that demonstrates the impact of the condition on the student’s learning. Testing dates should be within 3 years of matriculation. Documentation is submitted once during a student’s time at Saint Joseph's University.
Learning Disabilities
Learning disabilities encompass many different types of disabilities and impact a student’s performance in several different ways. Documentation for students with learning disabilities is submitted once, should be within 3 years of the date of matriculation and should include the criteria stipulated above. Additionally, a copy of the most current Individualized Education Plan (IEP) or 504 Accommodation Plan for the student may be submitted with the student’s documentation but cannot be the sole source of documentation.
*Please note: Annual documentation is not required for conditions that are considered stable and unchanging.