Documentation Guidelines

All documentation must be on a letterhead, typed, and dated in the form of a letter, report, psychological evaluation, or a high school IEP/504 plan. At the very minimum, the reports should include the information as listed below. The professional documenting the disability must be identified by name, title, and professional credentials; license or certification; area of specialty; and the state/province in which the professional practices.

The Americans with Disabilities Act, (Public Law 101-336, 1990) defines a disability as a physical or psychological impairment that substantially limits one or more major life activities, (i.e., learning, walking, talking, seeing, hearing, taking care of one’s self). The provision of reasonable accommodations is based on an assessment of the current impact of the student’s disability. As the manifestations of a disability may vary over time and in different settings, in most cases evaluations should have been conducted within the past year (i.e., low vision or neuromuscular conditions are often subject to change and should be updated for current functioning). Documentation should validate the need for services based on the individual’s current level of functioning in the educational setting.

Documentation must be current (generally, within three (3) years) and must include the following:

  • Exact diagnosis of the disability
  • Degree of current functioning loss
  • Limitations of the disability and its effect on the student’s ability to learn
  • A recommendation for the types of accommodations needed
  • If medications are taken, these should be clearly stated, as well as any potential side effects the medications may cause.

Guidelines for Documenting Disability by Category

To provide services to students with disabilities, the College is asking for voluntary self-identification of students with a specific disability. This information will be kept confidential and will be used to aid you, the student, in achieving your fullest potential while enrolled in postsecondary education.

Attention Deficit/Hyperactive Disorder (ADHD or Attention Deficit Disorder [ADD])

Documentation should be in the form of a formal letter or medical report. The diagnostic report should include the following components:

  • Summary of assessment procedures and evaluation instruments used to determine the diagnosis. A summary from a physician who has been treating the student for ADHD/ADD is also acceptable.
  • History of symptoms
  • Severity of the disorder
  • Information regarding medications prescribed and possible side effects that may impact the student’s academic performance
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does ADHD/ADD affect the student’s ability to learn?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting

Autism Spectrum Disorder

Documentation should be in the form of an evaluation, formal letter, or medical report. The diagnostic report should include the following components:

  • Summary of assessment procedures and evaluation instruments used to determine the diagnosis. A summary from a physician who has been treating the student is also acceptable.
  • History of symptoms
  • Severity of the disorder
  • Information regarding medications prescribed and possible side effects that may impact the student’s academic performance
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does the Asperger’s or Autism Spectrum affect the student’s ability to learn?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting

Blind or Low Vision

Documentation should be in the form of an evaluation or medical letter from an ophthalmologist or optometrist. The diagnostic report should include the following components:

  • Letter or documentation from an agency specializing in working with and assisting individuals who are blind or have low vision (Division of Blind Services)
  • History and severity of symptoms
  • Information regarding functional limitations or barriers connected to the student’s vision loss within the academic setting (How does vision loss or blindness impair the student’s ability to learn?)
  • If relevant, a description of the expected progression or stability of the impact of the condition over time
  • An ocular assessment or evaluation from an ophthalmologist or low-vision evaluation of residual visual function that, where appropriate, should assess the student’s visual loss both with and without the use of mitigating measures, such as the use of eyeglasses or other sensory devices
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting
  • Visual impairment is defined by the State of Florida as disorders in the structure and function of the eye as manifested by at least one of the following: visual acuity of 20/70 or less in the better eye after the best possible correction, a peripheral field so constricted that it affects one’s ability to function in an educational setting, or a progressive loss of vision which may affect one’s ability to function in an educational setting. Examples include, but are not limited to, cataracts, glaucoma, nystagmus, retinal detachment, retinitis pigmentosa, and strabismus.

Deaf or Hard of Hearing

Documentation should be in the form of an evaluation or audiology report. The diagnostic report should include the following components:

  • Letter or report from an audiologist or otolaryngologist
  • History and severity of symptoms
  • Severity of the disorder
  • Information regarding medications prescribed and possible side effects that may impact the student’s academic performance
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does deafness or hard of hearing affect the student’s ability to learn?)
  • An audiological evaluation and/or audiogram should assess the student’s hearing loss (dB levels) both with and without the use of mitigating measures, such as the use of hearing aids
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting (sign language interpreter, real-time captioning, note-takers, etc.)
  • A hearing impairment is defined by the state of Florida as a loss of thirty (30) decibels or greater, pure tone average of 500, 1000, and 4000 (Hz), unaided, in the better ear. Examples include, but are not limited to, conductive hearing impairment or deafness, sensorineural hearing impairment or deafness, high or low tone hearing loss or deafness, and acoustic trauma hearing loss or deafness.

Orthopedic Impairment

Documentation should be in the form of a formal letter or medical report. The diagnostic report should include the following components:

  • Letter from a physician qualified to diagnose and treat the condition
  • Identification of the specific orthopedic condition preferred
  • History of presenting symptoms
  • Duration and severity of the impairment
  • Information about side effects of medication currently prescribed
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does the disability impair the student from learning?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting

Other Health Disabilities

Documentation should be in the form of a formal letter or medical report. The diagnostic report should include the following components:

  • Letter from a physician qualified to diagnose and treat the condition
  • Identification of the specific medical condition preferred
  • History and severity of the condition
  • Information regarding medications prescribed and possible side effects that may impact the student’s academic performance
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does the disability impair the student from learning?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting

Psychological/Emotional/Behavioral Disability

Documentation should be in the form of a formal letter or medical report. The diagnostic report should include the following components:

  • Letter from a physician, psychologist, psychiatrist, licensed social worker, or licensed mental health counselor qualified to diagnose and treat the condition
  • History of symptoms
  • Duration and severity of the disorder
  • Identification of a specific psychological, emotional, or behavioral disability preferred
  • Information regarding medications prescribed and possible side effects that may impact the student’s academic performance
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does the disability impair the student from learning?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting

Specific Learning Disability

Documentation should be in the form of a psychological evaluation. The diagnostic report should include the following components:

  • Psycho-educational evaluation or neuro-psychological evaluation
  • A specific diagnosis preferred
  • History of symptoms
  • Duration and severity of symptoms
  • Evaluations based on adult norms preferred
  • IQ evaluation narrative, scores, and sub-test scores help determine reasonable accommodations.
  • Information regarding medications prescribed and possible side effects that may impact the student’s academic performance
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does the disability impair the student from learning?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting

Specific Learning Disability Definition

A disorder in one or more of the basic psychological or neurological processes involved in understanding or using spoken or written language. Disorders may be manifested in listening, thinking, reading, writing, spelling, or performing arithmetic calculations. Examples include dyslexia, dysgraphia, dysphasia, dyscalculia, and other specific learning disabilities in the basic psychological or neurological processes. Such disorders do not include learning problems, which are due primarily to visual, hearing, physical, or intellectual disability, emotional disturbance, or environmental deprivation.

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. The 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. Evidence of a substantial limitation to learning or other major life activity must be provided.

Tests for Assessing Adolescents and Adults

When selecting a battery of tests, it is critical to consider the technical adequacy of instruments including their reliability, validity, and standardization on an appropriate norm group. The following list states the recommended tests for screening specific learning disabilities:

Aptitude

  • Wechsler Adult Intelligence Scale – IV (WAIS-IV)
  • Stanford-Binet Intelligence Scale (5th edition)

Academic Achievement

  • Woodcock-Johnson Test of Achievement – Third Edition
  • Wechsler Individual Achievement Test (WIAT) or specific achievement tests, such as the Nelson-Denny Reading Skills Test
  • Stanford Diagnostics Mathematics Test
  • Test of Written Language (TOWL 4)
  • Woodcock Reading Mastery Tests – Third Edition

Information Processing

  • Woodcock-Johnson Test of Cognitive Abilities – Third Edition

IQ Evaluation

  • Wechsler Adult Intelligence Scale (WAIS-IV)
  • Reynolds (RAIS)

Other Documentation Accepted

An IEP (Individualized Education Plan) will be accepted for basic accommodations (i.e., extended time on tests and in-class assignments and use of a tape recorder). The IEP must have a diagnosis and signature page.

Speech and Language Impairment

Documentation should be in the form of an evaluation or formal letter from a speech pathologist. The diagnostic report should include the following components:

  • Letter from a physician or practitioner qualified to diagnose and treat the disorder
  • History of symptoms
  • Duration and severity of impairment
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does the disability impair the student from learning?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting

Traumatic Brain Injury

Documentation should be in the form of an evaluation, formal letter, or medical report. The diagnostic report should include the following components:

  • Psycho-educational evaluation; neuro-psychological evaluation; cognitive-processing narrative, scores, and sub-test scores; and IQ evaluation narrative, scores, and sub-test scores are helpful when determining reasonable accommodations.
  • History of presenting symptoms
  • Relevant medical and medication history
  • Duration and severity of injury
  • Information regarding medications prescribed and possible side effects that may impact the student’s academic performance
  • Information describing current functional limitations or barriers within the academic environment and other settings (How does the disability impair the student from learning?)
  • Recommendations for reasonable accommodations that will help the student succeed within an academic setting