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Documentation Guidelines
Documentation should include the following elements:
- A diagnostic statement identifying the specific disability, date of the most current diagnostic evaluation (within three to five years), and the date of the original diagnosis.
- A description of the diagnostic tests, methods, and/or criteria used including specific test results (standardized test scores), and the examiner’s narrative.
- A description of the current functional impact of the disability. This may be in the form of an examiner's narrative, and/or an interview, but must have a rational relationship to diagnostic assessments. Current documentation is defined using adult norms.
- A statement indicating treatments, medications, or assistive devices/services currently prescribed or in use, with a description of the mediating effects and potential side effects from such treatments.
- A description of the expected progression or stability of the impact of the disability over time, particularly the next five years.
- A history of previous accommodations and their impact.
- The credentials of the diagnosing professional, if not clear from the letterhead or other forms. The diagnosing professional may not be a family member.
- Documentation prepared for specific non-educational venues (i.e. Social Security Administration, Department of Veterans Affairs, etc.) may not meet the criteria as set forth by the ODS.
- IEP or 504 plans will not be considered sufficient documentation unless accompanied by a current and complete evaluation.
Beyond these nine elements needed for documentation, recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or collateral support services will be considered on a case-by-case basis.
Qualified professionals may refer to the Educational Testing Services Guidelines for Attention Deficit Disorder, Learning Disability, or Psychological Disability for more specific information regarding the documentation of a disability. Copies of each may be obtained from the ETS website www.ets.org.
Guidelines for Documentation of a Specific Disability
Learning Disability
Cadets with a learning disability are required to submit a comprehensive psychological and educational evaluation. Assessment, and any resulting diagnosis, must consist of and be based on a comprehensive assessment battery that does not rely on any one test or subtest (see general documentation guidelines). The ODS recognizes that once a person is diagnosed as having a qualified learning disability under the Americans with Disabilities Act, the disability is normally viewed as life-long. Although the learning disability will continue, the academic impact may change in different educational settings. Therefore, documentation for learning disabilities should include current measures, within the past three to five years, using adult-normed instruments, when appropriate, of the following:
- Aptitude / Cognitive Ability (e.g. WAIS-IV),
- Academic Achievement (e.g. current levels of functioning in reading, mathematics, oral and written language),
- Information Processing (e.g. short, long-term, working memory; visual and auditory processing; executive functioning).
A qualified professional must conduct the evaluation.
Attention Deficit Hyperactivity Disorder (ADHD)
Cadets with Attention Deficit Hyperactivity Disorder (ADHD) are required to submit comprehensive documentation that substantiates the ADHD. This documentation should include evidence of:
- Early Impairment – Evidence of early impairment although it may not have been formally diagnosed and how symptoms manifested in more than one setting, relevant historical information is essential;
- Evidence of current impairment;
- Relevant testing information (see documentation guidelines);
- Interpretive summary based on a comprehensive evaluation;
A qualified professional must conduct the evaluation.
In the case of all disabilities, documentation must indicate that the disability substantially limits some major life activity, including learning.
Cadets with a psychological disability are provided accommodations and coordinated support services through the ODS. Support services and accommodations are determined by the individual diagnostic information submitted by the cadet. Because psychological disabilities can change over time, current diagnosis is critical for providing appropriate accommodations. Therefore, documentation may be required on a yearly basis.
The following information will be needed:
Qualifications of the Evaluator
The documentation must include the following information and be typed on letterhead, dated, and signed:
- Names, titles, address and phone numbers of evaluator(s)
- License/certification, area of specialization, place of employment of evaluator(s)
- Documentation for psychological disabilities should come from primary health care professionals, psychiatrists, psychologists, psychological nurses, and other appropriate licensed mental health professionals.
- The diagnosing professional may not be a relative.
Diagnosis
The documentation must include a clear statement of the individual's psychological condition (DSM V diagnosis with Axes I, II, and V), with a description of diagnostic tests, methods, and/or criteria used.
Evaluation and Treatment
The documentation must give dates of evaluation or treatment (from _____ to_____ ) in order to establish the history of the condition and recency of the evaluation (must be within the last year). This should include specific results and the examiner's narrative interpretation. The evaluation should include treatments, medications, or assistive devices/services currently prescribed or in use. In addition, please provide a description of the expected progression or stability of the impact of the disability over time, particularly the next five years.
If this person has been referred for a complete battery of testing for learning disabilities or Attention Deficit/Hyperactivity Disorder to rule out any co-morbidity, please provide a copy of the documentation and date completed.
Accommodations
The documentation should indicate how the individual's condition might affect him/her in the academic/college setting. The evaluation should list functional limitations experienced by the cadet. This is very helpful in choosing appropriate accommodations.
NOTE: Beyond the four (4) elements needed for documentation, recommendations for accommodations, adaptive device, assistive services, compensatory strategies, and/or collateral support services (i.e. counseling, etc.) will be considered within the context of the cadet's program.
NOTE TO CADETS: Due to the nature of Psychological Disabilities, recency of documentation is critical for providing appropriate accommodations and support services. Depending on the disability, evaluations may need to be updated as often as every six (6) months.