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Documentation Guidelines

Psychiatric Disability Documentation

Students requesting accommodations under the Americans with Disabilities Act (ADA) and/or Section 504 of the Rehabilitation Act of 1973 must provide documentation of the existence of a psychiatric disability which substantially limits a major life activity.
Documentation Requirements:

  1. Currency of documentation - Documentation must be current, provided within the past year, by a licensed psychiatrist or psychologist.The name and professional credentials of the evaluator will be indicated including license number.
  2. DSM-IV diagnosis - A complete DSM-IV 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 - A complete description of the impact on academic functioning of the student's psychiatric symptoms must be provided.Descriptions of impact upon study skills, classroom behavior, test-taking and organizing research would be examples of academic functioning.
  4. . Recommendations for academic accommodations - Recommendations for academic accommodations must be based upon both #2 and #3 above. Academic accommodations which are recommended must be related to the diagnostic information and its impact upon student functioning.

Attention Deficit Hyperactivity Disorder (ADD/ADHD) Documentation

Students requesting accommodations and/or support services under the Americans with Disabilities Act (ADA) and/or Section 504 of the Rehabilitation Act of 1973 must provide documentation of the existence of a disability which substantially limits a major life activity. In order to accurately determine the appropriate accommodations, the documentation should be current, within 3 years. It may be appropriate to extend the testing limit to 5 years if the data are reflective of the student's current functioning. In all cases, the documentation should be appropriate to the anticipated setting.
Documentation should include, but not be limited to, the following:

  1. Name and professional credentials of the evaluator. Evaluations must be done by a licensed psychologist with training and experience in the evaluation of the adolescent/adult psychiatric disorders and specifically with ADHD.
  2. Diagnosis according to DSM-IV criteria with explanation of instruments used to reach the diagnosis. Students are encouraged to pursue and submit the results of psychological/ neuropsychological and educational achievement testing. While these results are not required for a diagnosis of ADHD, many students with ADHD also have learning disabilities and these test results are useful for academic and program planning.
  3. Impact on academic functioning - A complete description of the impact of 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 consistent with #3.

Learning Disability Documentation

Students requesting accommodations and/or support services under the Americans with Disabilities Act (ADA) and/or Section 504 of the Rehabilitation Act of 1973 must provide documentation of the existence of a learning disability which substantially limits a major life activity. In order to accurately determine the appropriate accommodations, the 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. In all cases, the documentation should be appropriate to the anticipated setting.
Documentation should include, but not be limited to, the following:

  1. Qualifications of the Evaluator. Evaluation must be done by a licensed psychologist with training and direct experience with an adolescent and adult LD population is essential. The name, title and professional credentials of the evaluator, including information about license or certification as well as the area of specialization, employment and state/province in which individual practices should be clearly stated in the documentation.
  2. Comprehensive Assessment. The neuropsychological or psycho-educational evaluation for the diagnosis of a specific learning disability must provide clear and specific evidence that a learning disability does or does not exist. Assessment, and any resulting diagnosis, should consist of and be based on 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. It should include assessments of:
    • Cognitive - A complete battery, appropriate for an adult population, with all subtest and standard scores reported. One of the following would be required: Wechsler Adult Intelligence Scale-Revised (WAIS-R), Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability, Kaufman Adolescent and Adult Intelligence Test.
    • 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. Examples of commonly used tools are: Woodcock-Johnson Psychoeducational Battery-Revised: Tests of Achievement, Stanford Test of Academic Skills (TASK), Wechsler Individual Achievement Test (WIAT), and Nelson-Denny Reading Skills Test.
    • 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. gathered from the comprehensive assessment, diagnostic interview, and examiner's observations of test behavior.
  3. Diagnosis. Identification of a specific Learning Disability based upon the information from the comprehensive assessment and a diagnostic interview.
  4. Clinical Summary. A diagnostic summary based on a comprehensive evaluation process is a necessary component of the report. The clinical summary should include:
    1. 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;
    2. indication of how patterns in the student's cognitive ability, achievement and information processing reflect the presence of a learning disability;
    3. 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;
    4. indication as to why specific accommodations are needed and how the effects of the specific disability are accommodated;
    5. any record of prior accommodation or auxiliary aids, including information about specific conditions under which the accommodations were used;
    6. specific recommendations for accommodations as well as an explanation as to why each accommodation is being recommended.

Physical Disability Documentation

Students requesting accommodations and/or support services under the Americans with Disabilities Act (ADA) and/or Section 504 of the Rehabilitation Act of 1973 must provide documentation of the disability which substantially limits a major life activity. In order to accurately determine the appropriate accommodations, the documentation should be current and reflective of the student's current functioning. In all cases, the documentation should be appropriate to the anticipated setting. 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.
Documentation should include, but not be limited to, the following:

  1. Name, title, and professional credentials of the evaluator - The evaluator should have training and expertise with the particular medical condition identified. The area of specialization as well as the state in which the individual practices must be included. All reports are requested to be signed and dated.
  2. . Diagnosis/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. Evaluation of impact - Documentation should indicate a substantial limitation and should include any prior history of accommodations needed.
  4. Recommended accommodations consistent with #2 and #3.

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