Documentation Guidelines

  • Documentation must come from a licensed professional (unrelated to the individual being evaluated) and trained in the appropriate specialty area. There must be a good match between the credentials of the individual making the diagnosis, and the condition being reported (e.g., an orthopedic limitation might be documented by a physician, but not a licensed psychologist.) Documentation that presents any question as to authenticity will be followed up with a consultation to verify information (e.g., hand-written letters.) Documentation must be dated, on letterhead, and signed by the evaluator. Documentation on prescription pads will not be accepted.
  • Documentation must include a description of the diagnostic criteria or the diagnostic tests used. This description should include the specific results of the diagnostic procedures, diagnostic tests utilized and dates administered. When available both summary data and specific test scores should be reported. Diagnostic methods used should be congruent with current professional diagnostic practices within the field. Informal or non-standardized evaluations should be described in enough detail that a professional colleague could understand their role and significance in the diagnostic process.
  • Documentation must include both a clear diagnostic statement and an explanation of the current manifestations or functional limitations of the condition, especially as they relate to academic performance.  Conditions diagnosed according to DSM standards should note the appropriate DSM code.  The statement of diagnosis and explanation of functional limitations should be thorough enough to demonstrate whether or not a major life activity is substantially limited.
  • The evaluator must include specific recommendations for reasonable academic accommodations and a detailed explanation of the rationale for each recommendation as it relates to the specific functional limitations.
  • Documentation must be current, usually less than 3 years old. However, discretion may be used in accepting documentation of conditions that are permanent or non-varying (e.g., a sensory disability). Likewise, some chronic and/or changing conditions will warrant more current documentation and/or more frequent updates in order to provide an accurate picture of functioning.
  • Documentation should include information regarding the impact of the disability condition on major life activities (i.e., walking, talking, learning, working, seeing, hearing) including the impact of medications, other treatments, and the concomitant side effects.