Documentation Guidelines

A disability is defined as a physical, mental, cognitive, or developmental condition which significantly impacts one or more major life activity. To receive disability-related accommodations under the Americans with Disabilities Act (ADA), appropriate documentation of a student’s disability is required. The documentation information will remain in a confidential file with Accessibility Resource Center. Accommodations are approved on a case-by-case, individualized basis.

Documentation guides the accommodation process by:

  • establishing a student's eligibility for services,
  • defining the impact of a student’s condition(s) in an academic environment, and 
  • identifying appropriate strategies and reasonable accommodations to facilitate equal access.

Attention Deficit Hyperactivity Disorder (ADD/ADHD) Documentation

Documentation should include, but is not limited to, the following:

  1. Qualifications of the Evaluator. The name, title, and professional credentials of the evaluator should be clearly stated in the documentation. All reports must be typed on letterhead, dated, and signed.
  2. Diagnosis. Diagnosis according to DSM-V criteria with explanation of instruments or methods used to reach the diagnosis.
  3. Impact on Academic Functioning. A complete description of the impact of ADD/ADHD on the student’s academic functioning must be provided. Descriptions of impact upon study skills, classroom behavior, test-taking and organizing research would be examples of academic functioning.
  4. Recommended Accommodations. Specific recommendations for accommodations consistent with and #3 above, as well as an explanation as to why each accommodation is being recommended.

Students are encouraged to pursue and submit the results of a neuropsychological or psycho-educational evaluation. While these results are not required for a diagnosis of ADD/ADHD, many students with ADD/ADHD also have learning disabilities and these test results are useful for academic and program planning.

Learning Disability Documentation

Documentation should include, but not be limited to, the following:

  1. Qualifications of the Evaluator. Evaluation must be done by a licensed psychologist. The name, title, and professional credentials of the evaluator should be clearly stated in the documentation. All reports must be typed on letterhead, dated, and signed.
  2. Comprehensive Assessment. The neuropsychological or psycho-educational evaluation used to diagnose the specific learning disability. This assessment must provide clear and specific evidence that a learning disability does or does not exist and should consist of a comprehensive assessment battery which does not rely on any one test or subtest. This assessment should include a diagnostic interview to determine medical, developmental, psychosocial, family, academic, and employment histories, and should also include assessments of:
    • Cognitive Skills - A complete battery, appropriate for an adult population, with all subtest and standard scores reported.
    • Achievement - A complete battery relevant to area(s) of suspected disability(s), often to include a reading assessment, with all subtest and standard scores reported. 
    • Information Processing - An examination of the student's processing strengths and weaknesses to include areas such as short- and long-term memory, processing speed, metacognition, etc.
  3. Diagnosis. Identification of a specific Learning Disability.
  4. Clinical Summary. A diagnostic summary based on a comprehensive evaluation process is a necessary component of the report. The clinical summary should include:
    • demonstration of the evaluator's having ruled out alternative explanations for academic problems as a result of poor education, poor motivation and/or study skills, emotional problems, attention problems and cultural language differences
    • indication of how patterns in the student's cognitive ability, achievement and information processing reflect the presence of a learning disability
    • indication of the substantial limitation to learning or other major life activity presented by the learning disability and the degree to which it impacts the individual in the learning context for which accommodations are being requested
    • indication as to why specific accommodations are needed and how the effects of the specific disability are accommodated
    • any record of prior accommodation or auxiliary aids, including information about specific conditions under which the accommodations were used
    • specific recommendations for accommodations as well as an explanation as to why each accommodation is being recommended
  5. Currency of Documentation. In order to accurately determine appropriate accommodations, documentation should be current, within 3 years. It may be appropriate to extend the testing limit to 5 years if the testing is reflective of the student's current functioning.

Medical Disability Documentation

Documentation should include, but not be limited to, the following:

  1. Qualifications of the Evaluator. The evaluator should have training and expertise with the particular medical condition identified. The name, title, and professional credentials of the evaluator should be clearly stated in the documentation. All reports must be typed on letterhead, dated, and signed.
  2. Diagnosis and Assessment. A current medical diagnosis including appropriate medical reports, relevant medical history, and a clinical summary should be provided. The assessment should validate the need for services based on the impact of the student's disability on academic performance and level of functioning in an educational setting.
  3. Impact on Current Functioning. Documentation should indicate a substantial limitation on a major life activity presented by the disability and should include any prior history of accommodations received.
  4. Treatment. Documentation should describe the expected duration, progression, and stability of the condition. It should also include information about ongoing treatment plans.
  5. Recommended Accommodations. Specific recommendations for accommodations consistent with #2 and #3 above, as well as an explanation as to why each accommodation is being recommended.
  6. Currency of Documentation. In order to accurately determine appropriate accommodations, the documentation should be current and reflective of the student's current functioning. Accommodations provided for individuals with temporary disabling conditions may be subject to periodic review. Bellarmine University healthcare providers may review materials submitted by off campus healthcare professionals to assist in determining appropriate accommodations.

Neurological Documentation

Documentation must include the following information:

  1. Qualifications of the Evaluator. Documentation of a neurological disability must be provided by a neurologist, neuropsychologist, neurosurgeon, or other appropriately trained medical doctor with expertise related to the particular medical condition identified. The name, title, and professional credentials of the evaluator should be clearly stated in the documentation. All reports must be typed on letterhead, dated, and signed.
  2. Diagnosis and Assessment. A current medical diagnosis including appropriate medical reports, relevant medical history, and a clinical summary should be provided. This assessment should validate the need for services based on the impact of the student's disability on academic performance and level of functioning in an educational setting.
  3. Impact on Current Functioning. Documentation should indicate a substantial limitation on a major life activity and should include any prior history of accommodations received.
  4. Treatment. Documentation should describe the expected duration, progression, and stability of the condition. It should also include information about ongoing treatment plans.
  5. Recommended Accommodations. Specific recommendations for accommodations consistent with #2 and #3 above, as well as an explanation as to why each accommodation is being recommended.
  6. Currency of Documentation. In order to accurately determine appropriate accommodations, the documentation should be current and reflective of the student's current functioning. Accommodations provided for individuals with temporary disabling conditions may be subject to periodic review. Bellarmine University healthcare providers may review materials submitted by off campus healthcare professionals to assist in determining appropriate accommodations.

Psychological Disability Documentation

Documentation should include, but is not limited to, the following:

  1. Qualifications of the Evaluator. Evaluation must be done by a licensed psychiatrist, psychologist, or other mental health care provider. The name, title, and professional credentials of the evaluator should be clearly stated in the documentation. All reports must be typed on letterhead, dated, and signed.
  2. Diagnosis. A complete DSM-V diagnosis must be provided with an accompanying description of the specific symptoms the student experiences. This diagnosis should be based upon a comprehensive clinical interview and assessment instruments as needed.
  3. Impact on Academic Functioning. Documentation should indicate a substantial imitation on a major life activity presented by the disability. A complete description of the impact of the student's psychiatric symptoms on academic functioning must be provided. Descriptions of impact upon study skills, classroom behavior, test-taking, and organizing research would be examples of academic functioning.
  4. Recommended Accommodations. Specific recommendations for accommodations consistent with #2 and #3 above, as well as an explanation as to why each accommodation is being recommended.
  5. Currency of Documentation. In order to accurately determine appropriate accommodations, the documentation should be current, within the past year, and reflective of the student’s current functioning.