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Suggested Documentation Guidelines
For ADD/ HD:
- Documentation must include a medical or clinical diagnosis of
ADD/HD based on DSM-IV criteria and a rationale for the diagnosis.
- The evaluation must be performed by an appropriate professional,
a medical doctor or a clinical psychologist, who is knowledgeable
regarding ADD/HD. The evaluator's name, title, and professional
credentials and affiliation should be provided.
- The documentation should include the following:
- Quantitative and qualitative information that supports the
diagnosis;
- Summary and interpretation of assessment instruments (formal
assessment instruments and/or clinical interview);
- Information regarding the specific academic functions affected
by and the severity of the disability (e.g., ability to sustain
attention, distraction index);
- Recommendations for and compliance to prescriptive treatment,
including medication;
- Recommendations for academic accommodations based on specific
features/symptoms of disability;
- Investigation/evaluation of dual and/or confounding diagnosis
(e.g., mood, behavioral, neurological, learning, personality
disorders).
- Documentation must reflect the current (within the past year)
array of symptoms/features and level of functioning; if the documentation
does not, students may be required to submit up-dated information
and/or documentation.
- Neither a 504 plan nor an individualized educational plan (IEP)
constitute sufficient documentation but may be submitted along
with a medical or clinical evaluation.
For Psychiatric Disabilities:
- Documentation must include a medical or clinical diagnosis of
a psychiatric disability based on DSM-IV criteria and a rationale
for the diagnosis.
- The evaluation must be performed by an appropriate professional:
a psychiatrist, a clinical psychologist, or a clinical social worker. The
evaluator's name, title, and professional credentials and affiliation
should be provided.
- The documentation should include the following:
- Information regarding the severity of the disability and the
specific academic functions affected by the disability and/or
medication (e.g., ability to concentrate, ability to attend class
regularly, ability to interact in small/large groups);
- Recommendations for and compliance to prescriptive treatment,
including medication;
- Recommendations for academic accommodations based on specific
features/symptoms of disability.
- Documentation must reflect the current array of symptoms/features
and level of functioning; if the documentation does not,
students may be required to submit up-dated information and/or documentation.
For Cognitive Disabilities:
- A psycho-educational evaluation that provides a diagnosis of
a cognitive disability must be submitted. A statement indicating
the current status and impact of the disability in an academic
setting should be included. If another diagnosis is applicable
(e.g., ADD/HD), mood disorder), it should be stated.
- The evaluation must be performed by a certified/licensed professional.
The evaluator's name, title, and professional credentials and affiliation
should be provided.
- The evaluation should be based on a comprehensive assessment
battery:
- Aptitude: Average broad cognitive functioning
must be demonstrated on an individually administered intelligence
test, such as the WAIS-R, WAIS-III, WISC-R, WISC-III, or WJ-R
Cognitive Battery. Subscales/subtests scores should be listed.
- Academic Achievement: A comprehensive academic
achievement battery, such as WJ-R, must document achievement
deficits relative to potential. The battery should include current
levels of academic functioning in relevant areas, such as reading
(comprehension, decoding), oral and written language, and mathematics.
Standard scores, grade levels, and percentages for subtests administered
should be stated.
- Information Processing: Specific areas of
information processing (e.g., short- and long-term memory, abstract
reasoning) should be assessed.
- Social-Emotional Assessment: To provide information
needed to establish appropriate services, a social-emotional
assessment, using formal assessment instruments and/or clinical
interview, should be conducted.
- Clinical Summary: A diagnostic summary should
present a diagnosis of a cognitive disability; provide impressions
of the testing situation; interpret the testing data; indicate
how patterns in cognitive ability, achievement, and information
processing reflect the disability; and recommend specific
accommodations based on disability-related deficits.
- For students just graduating high school, an evaluation reflecting
current levels of academic skill should have been administered
during their high school tenure; for students who have been
out of school for a number of years, documentation will be considered
on a case by case basis. Students may be required to
submit up-dated information and/or documentation.
- Additional documents that do not constitute sufficient documentation,
but that may be submitted in addition to a psychological or psycho-educational
evaluation are: an individualized educational plan (IEP), a 504 plan,
and/or an educational assessment.
For Physical and Sensory Disabilities:
- Documentation must include a medical diagnosis.
- The diagnosis and evaluation should be made by a medical doctor
or appropriate specialist licensed in the specific field of disability.
The evaluator's name, title, and professional credentials and affiliations
should be provided.
- The documentation should include the following:
- The stability of the disability (Is the disability stable,
progressive, fluctuating?);
- Information regarding the specific academic functions affected
by and the severity of the disability (e.g., ability to concentrate,
ability to attend class regularly);
- Recommendations for academic accommodations based on specific
features/symptoms of the disability (e.g., adaptive technology/equipment).
- The recency of the documentation is dependent on the nature/stability
of the disability.
- Documentation must reflect the current array of symptoms/features
and level of functioning; if the documentation does not, students
may be required to submit up-dated information and/or documentatin.
For Learning Disabilities:
- A psycho-educational or neuropsychological evaluation that provides
a diagnosis of a specific learning disability must be submitted. A
statement indicating the current (eleventh/twelfth grade) status
and impact of the learning disability in an academic setting should
be included. If another diagnosis is applicable (e.g., ADD/HD,
mood disorder), it should be stated.
- The evaluation must be performed by a professional who is certified/licensed
in the area of learning disabilities. The evaluator's name,
title, and professional credentials and affiliation should be provided.
- The evaluation should be based on a comprehensive assessment
battery:
- Aptitude: Average broad cognitive functioning
must be demonstrated on an individually administered intelligence
test, administered during high school tenure, such as the WAIS-R,
WAIS-III, WISC-R, WISC-III, or WJ-R Cognitive Battery. Subscales/subtests
scores should be listed.
- Academic Achievement: A comprehensive
academic achievement battery, such as WJ-R, must document achievement
deficits relative to potential. The battery should include
current levels of academic functioning in relevant areas, such
as reading (comprehension, decoding), oral and written language,
and mathematics. Standard scores, grade levels, and percentages
for subtests administered should be stated.
- Information Processing: Specific areas
of information processing (e.g., short- and long term memory,
auditory, and visual perception/processing, executive functioning)
should be assessed.
- Social-Emotional Assessment: To rule-out
a primary emotional basis for learning difficulties and provide
information needed to establish appropriate services, a social-emotional
assessment, using formal assessment instruments and/or clinical
interview, should be conducted.
- Clinical Summary: A diagnostic summary
should present a diagnosis of a specific learning disability;
provide impressions of the testing situation; interpret the testing
data; indicate how patterns in cognitive ability, achievement,
and information processing reflect the specific learning disability;
recommend specific accommodations based on disability-related
deficits; and rule out alternative explanations for and include
factors contributing to academic difficulties.
- For students just graduating high school, an evaluation reflecting
current levels of academic skills should have been administered
while in high school; for students who have been out of school
for a number of years, documentation will be considered on a case
by case basis. Students may be required to submit up-dated information
and/or documentation.
- Additional documents that do not constitute sufficient documentation,
but that may be submitted in addition to a psychological, psycho-educational,
or neuropsychological evaluation are: an individualized educational
plan (IEP), a 504 plan, and/or an educational assessment.
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