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GUIDELINES FOR DOCUMENTATION
In most cases, in order to be determined eligible for accommodations through the Department of Disability Services, an enrolled student (whether full- or part-time) with a disability/chronic medical condition should present documentation that contains information describing the student's current level of functioning within and outside the academic setting in the University.
The documentation should be submitted by a professional who is licensed/certified in the area for which the diagnosis is made and who is not related to the student. The report must be presented on practice letterhead and signed by the examiner.
Information for the Examiner:
Although this is not intended to be a template, we request that the information set out in this section be included in the report. Additional information needed for individuals with certain specific types of disability is listed in the next section.
- History of personal, social, medical and education activities as it pertains to the cause for evaluation.
- Diagnostic statement identifying the disability (ICD-DSM classification)
- Description of the diagnostic methodology used, including all data from appropriate instruments of evaluation. Information based on "screening" instruments is not acceptable
- Description of current substantial limitations as they relate to meeting the various demands of University life. The report should contain a discussion and evidence of impact as it relates to the actual academic achievement (or lack thereof) in the current time period and the past year (indicate any accommodations and/or services provided.) Information should also be included regarding the past two to three years explaining how and why the student's academic performance has, or has not, been affected by the Disability
- Expected progression or stability of the medical condition/disability.
- Medication - mitigation of impact and/or (expected) side effects.
- Co-morbid conditions - if multiple diagnoses are provided, please indicate the primary and secondary conditions and how each affects learning.
- Explanation of differential or exclusionary diagnosis
- Recommendations -Suggestions for accommodations should be directly linked to the impact of the disability and associated issues (e.g. medication) and not simply to the diagnosis.
Insufficient Documentation (and/or Evaluative Remarks)
- In cases where the documentation is incomplete, students will be asked to seek additional evaluation and/or clarifying information from the evaluator/medical provider regarding the documentation.
- Since the requirements for access in higher education are different than those for high school, IEP's (Individual Educational Plans), 504 Plans, and SOP's (Summary of Performance), although they provide information about a student's educational experiences, generally are not sufficient documentation to establish that the student is eligible for services and accommodations in an institution of higher education.
- In most cases documentation consisting only of a diagnosis, case or chart notes, and/or prescription pad notations is insufficient to determine the impact of a medical condition/disability, to address the issue of substantial limitations, and to develop reasonable accommodations.
If a student leaves the University for any reason, upon readmission he or she may be asked to submit updated documentation prior to receiving accommodations and/or services.
INFORMATION NEEDED FOR SPECIFIC MEDICAL CONDITIONS OR DISABILITIES
In addition to the information noted above, please consider and include information about the following issues in reports.
BLIND AND VISUALLY IMPAIRED
The documentation from an ophthalmologic or optometric report should include as applicable:
- specific diagnosis indicating current visual acuity
- near and distant vision (left/right, both eyes)
- visual fields, with and without corrective lenses
CHRONIC MEDICAL CONDITIONS
The documentation should explain the current functional limitations imposed by the medical condition.
- Specific diagnosis
- Constant or episodic - frequency and/or duration
- Medication(s) and possible effects
- Any other pertinent information that may assist DDS in determining reasonable accommodations.
COGNITIVE IMPAIRMENTS
(Examples: Learning Disabilities [LD], Traumatic (Acquired) Brain Injuries [TBI], Autism/Asperger's Syndrome, Attention Deficit Hyper Activity Disorder [ADHD])
The documentation should explain the current functional limitations imposed by the condition. The following should be included:
- Explanation of psychological and/or psycho-educational tests used. Indicate all tests data/scores used to support diagnosis
- Current medication including: dosage and side effects that the student is experiencing
- Interviews, surveys and other data collected to support diagnosis.
Re-Evaluation - The evaluator may choose to modify the testing battery for students who have been previously evaluated using instruments that are normed for adults or adolescents and not children. The administration of intelligence measures may not be necessary but the short form of an intelligence test may be acceptable in these situations. This would be the case if the disability is not directly evaluated by these measures and/or if the individual's scores have remained consistent over time.
DEAF AND HARD OF HEARING
The documentation should include a comprehensive audiological report including,
- a specific diagnosis
- date of onset (pre/post lingual)
- current hearing levels, stable or progressive
- speech reception levels, with and without hearing aids and/or assistive listening devices (ALDs)
PHYSICAL/MOBILITY IMPAIRMENTS
The documentation should identify functional limitations in respect to:
- Gross or fine motor functioning
- Whether the condition is permanent or temporary. If temporary, how long? (estimate)
PSYCHOLOGICAL/PSYCHIATRIC CONDITIONS
The documentation should explain the current functional limitations imposed by the condition. The following questions should be addressed:
- Basis on which Axis I and Axis II diagnoses were made
- If psychological and/or psycho-educational tests are used, indicate all tests data/scores used to support diagnosis
- Current medication including: dosage and side effects that the student is experiencing
- Short/long term prognosis
- Therapeutic interventions, compliance
- Educational Implications (be specific about the nature/severity of limitations)
With questions or concerns, please contact:
University of South Carolina Aiken
Office of Disability Services
Barb Riverdahl
Disability Services Coordinator
Aiken, SC 29801
V/T: 803-641-3609
FAX: 803-641-3677
TTY: 803-643-6818
Email: BarbR@usca.edu
Web: www.usca.edu/ds
