Documentation Guidelines
Disability Documentation Must:
Be Conducted by a Qualified Examiner
Professionals conducting assessments and providing diagnoses of disabilities and making recommendations for appropriate accommodations must be qualified to do so. The name, title, and professional credentials of the evaluator, including information about license or certification (e.g., licensed school psychologist) as well as the area of specialization, employment, and state in which the individual practices must be clearly stated in the documentation. The following professionals would generally be considered qualified to evaluate specific learning disabilities provided that they have additional training and experience in evaluating adolescent/adult learning disabilities: clinical or educational psychologists; school psychologists; neuropsychologists; learning disabilities specialists; medical doctors with training and experience in the assessment of learning problems in adolescents and adults. All reports must be submitted on letterhead and be signed and dated.
Be Current
Because the provision of all reasonable accommodations and services is based upon assessment of the current impact of the student's disabilities on his or her academic performance, it is in a student's best interest to provide recent and appropriate documentation. In most cases, this means that testing usually has been conducted within the past three years.
(Note: this requirement does not apply to physical or sensory disabilities of a permanent or unchanging nature.)
Be Comprehensive
Documentation must demonstrate the need for services based on the individual's current level of functioning in the educational setting. A school plan such as an individualized educational plan (IEP) or a 504 plan is insufficient documentation in and of itself but can be included as part of a more comprehensive assessment. A comprehensive assessment and the resulting diagnostic report should include a) a diagnostic interview; and b) assessments of aptitude, academic achievement, and information processing; and c) informal observations of the student during the test administration.
- Diagnostic Interview
- A description of the presenting problem(s);
- Developmental history;
- Relevant medical history including the absence of a medical basis for the present symptoms;
- Academic history including results of prior standardized testing; reports of classroom performance;
- Relevant family medical and disability history, including primary language of the home, and the student's current level of fluency of English;
- Psychosocial history;
- A discussion of dual diagnosis, alternative or co-existing mood, behavioral, neurological, and/or personality disorders along with any history of relevant medication and current use which may impact the individual's learning; and exploration of possible alternatives which may mimic a learning disability when, in fact, one is not present.
- Assessment Measures Aptitude/ Cognitive Ability
- A complete intellectual assessment with all subtests and standard scores reported, along with a narrative interpretation of scores, is essential. Examples of tests are the WAIS-III, WJ-III Cognitive, Stanford Binet, etc.
- Academic Achievement
- A comprehensive academic achievement battery with all subtests and standard scores reported for those subtests administered, along with a narrative interpretation of scores, is essential. The battery must include current levels of academic functioning in relevant areas such as reading (decoding and comprehension), mathematics, and oral and written language.
- Information Processing
- Specific areas of information processing (e.g., short- and long-term memory; sequential memory; auditory and visual perception/ processing; processing speed; executive functioning; motor ability) is desired.
- Other Assessments as Needed
- Reports of any additional assessments should provide a rationale for their use, i.e., to provide a differential diagnosis.
Contain a Specific Diagnosis
The documentation must include a specific diagnosis, most typically from the Diagnostic Statistical Manual of Mental Disorders (DSM-IV). Nonspecific diagnoses, such as individual "learning styles," "learning differences,� academic problems," "slow reader," and "test anxiety" in and of themselves do not constitute a disability. It is important to rule out alternative explanations for problems in learning, such as emotional, attentional, or motivational problems, that may be interfering with learning but do not constitute a learning disability. The evaluator is encouraged to use direct language in the diagnosis and documentation of a learning disability, avoiding the use of such terms as "suggests" or "is indicative of." If the data indicate that a learning disability is not present, the evaluator must state that conclusion in the report.
Describe the functional limitations resulting from the disability or disabilities, and make specific recommendations for accommodations needed to address these limitations.
It is important to recognize that accommodation needs can change over time and are not always identified through the initial diagnostic process. Conversely, a prior history of accommodation, without demonstration of a current need, does not in and of itself warrant the provision of a like accommodation. The diagnostic report must include specific recommendations for accommodation(s) as well as a detailed explanation of why each accommodation is recommended. The evaluator(s) must describe the impact the diagnosed disability has on a specific major life activity (e.g. learning) as well as the degree of significance of this impact on the individual. The evaluator(s) should support recommendations with specific test results or clinical observations. If no prior accommodation(s) has been provided, the qualified professional and/or the student should include a detailed explanation of why no accommodation(s) was used in the past and why an accommodation(s) is needed at this time.