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Documentation Requirements

The purpose of objective evidence (documentation) of a disability is two-fold: to establish protection from discrimination and to determine the accommodations to which the individual may be entitled.

Students, faculty or staff 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 that substantially limits a major life activity.  In order to accurately determine the appropriate accommodations, the documentation should be current. This could mean within 3 years or longer for a learning disability if the person submitting documentation was evaluated as an adult. This could be within the last few weeks for a new or temporary condition.  We do require periodic updates for physical conditions which are not chronic, as well as psychological conditions.  In all cases, the documentation should be appropriate to the anticipated setting.

Brown University has adopted the following guidelines for documentation based on the Seven Essential Elements of Quality Disability Documentation published by AHEAD (Association on Higher Education and Disability) in 2004.

 

Documentation should include though not necessarily be limited to the following:

1. The credentials of the evaluator(s).

Quality documentation will be provided by a licensed or otherwise properly credentialed professional who has undergone appropriate training, has relevant experience, and has no personal relationship with the client.

2. A diagnostic statement identifying the disability.

A clear diagnostic statement will describe how the condition was diagnosed, provide information on the functional impact, and detail the typical progression or prognosis of the condition.  Diagnosis codes are helpful but not required.

3. A description of the diagnostic methodology used.

Quality documentation will include a description of the diagnostic criteria, evaluation methods, procedures, tests, and dates of administration, along with a clinical narrative, observation, and specific results.  Where appropriate to the nature of the disability, having both summary data and specific test scores is expected.
* (Please refer to the list of appropriate diagnostic tools for ADHD and LD at the end of this document.)

4. A description of the current functional limitations.

A description of how the disabling condition(s) currently impacts the individual for the purpose of establishing a disability and identifying possible accommodations.  The best quality documentation is thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition.

5. A description of the expected progression or stability of the disability.  

Documentation is helpful when it provides information on expected changes in the functional impact of the disability over time and context.  Descriptions of the cyclical or episodic nature of the disability and known or suspected environmental triggers to episodes provide opportunities to anticipate and plan for varying functional impacts.

6. A description of current and/or past accommodations, services, and/or medications.

Complete documentation includes a description of both current and past medications, auxiliary aids, assistive devices, support services, and accommodations, including their effectiveness in alleviating functional impacts of the disability.

7. Recommendations for accommodations.

This can include recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or collateral support as appropriate to the functional limitations.  “While the post-secondary institution has no obligation to provide or adopt recommendations made by outside entities, those that are congruent with the programs, services and benefits offered by the college or program may be appropriate.  When recommendations go beyond equitable and inclusive services and benefits, they may still be useful in suggesting alternative accommodations and/or services.”  (AHEAD, 2004)

 

When documenting ADHD, the following instruments are recommended:

  • Interview with parents (or another adult with integrity of knowledge of patient) reflecting concerns about client, history of each concern, review of developmental domains (motor, sensory, language, intellectual, self-help, academic, emotional, and social), review of family relationships, review of parent management tactics, review of family social circumstances, developmental/medical history, prior evaluations, information regarding onset, longevity, severity of symptoms and treatment.

  • Behavior rating scales from parents (or another adult with integrity of knowledge of patient) such as ADHD Rating Scale (DSM-IV).

  • Behavior rating scales from teachers (when the student is matriculating directly from high school) to include broad band measures, such as Teacher Report Form (Child Behavior Checklist for teachers) and narrow band measures, such as the ADHD Rating Scale (DSM-IV).

  • Behavior ratings scales for the client to include self-rating on broad band measures, such as the Child Behavior Checklist (Adult Self) and/or Wender Utah Rating Scale (WURS) and narrow band measures, such as ADHD (DSM-IV) for current functioning and recall of childhood functioning.

  • Structured psychiatric interview along with objective measures (SCL-90-R, MMPI-II) to rule out schizophrenia, major disorders, borderline personality disorders, pervasive development disorders (autism, Asperger's) and mental retardation.

  • Documentation of impairment where available (school, mental health, pediatric, other medical, work and driving records).

 

We recommend that in addition to the instruments listed above, the following assessments also be conducted in order to identify  possible co-existing learning issues and to assist in determining the most appropriate accommodations.

*Documentation of Learning Disorders should include assessments of:

Cognitive functioning

A complete battery of tests, appropriate for an adult should be conducted, with all  subtest and standard scores reported. One of the following would be required: Wechsler Adult Intelligence Scale (WAIS-III), Woodcock-Johnson Psychoeducational Battery IV: Tests of Cognitive Ability, or the 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 IV: 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 client's processing strengths and weaknesses
to include areas such as short and long term memory, processing speed, meta-cognition, etc.
gathered from the comprehensive assessment, diagnostic interview, and examiner's observations
of test behavior.