Disability Support Services - a Division of Student Affairs at the University of Central Oklahoma

Documentation Guidelines

Medical documentation addressing the functional limitations of one’s disability as it relates to the accommodations requested must be submitted for review by a Disability Support Services provider.  Documentation must be typed or word-processed and printed on the letterhead of either the practitioner or the agency hosting the practice. Handwritten notes on prescription pads or handwritten treatment records will not be accepted.

1. The credentials of the evaluator(s)

Documentation must be provided by a licensed or otherwise properly credentialed professional who has undergone appropriate and comprehensive training, has relevant experience, and has no personal relationship with the individual being evaluated. The match must be between the credentials of the individual making the diagnosis and the condition being reported is expected (e.g., an orthopedic limitation might be documented by a physician, but not a licensed psychologist).

 

2. A diagnostic statement identifying the disability

 Documentation must include a clear diagnostic statement that describes how the condition was diagnosed, provides information on the functional impact, and details the typical progression or prognosis of the condition. While diagnostic codes from the Diagnostic Statistical Manual of the American Psychiatric Association (DSM) or the International Classification of Functioning, Disability and Health (ICD-9) of the World Health Organization are helpful in providing this information, a full clinical description will also convey the necessary information.

 

3. A description of the diagnostic methodology used

Documentation should include a description of the diagnostic criteria, evaluation methods, procedures, tests and dates of administration, as well as a clinical narrative, observation, and specific results. Where appropriate to the nature of the disability, having both summary data and specific test scores (with the norming population identified) within the report is recommended.  Diagnostic methods that are congruent with the particular disability and current professional practices in the field are expected. Methods may include formal instruments, medical examinations, structured interview protocols, performance observations and unstructured interviews. If results from informal, non-standardized or less common methods of evaluation are reported, an explanation of their role and significance in the diagnostic process will strengthen their value in providing useful information.

 

4. A description of the current functional limitations

Information on how the disabling condition(s) currently impacts the individual provides useful information for both establishing a disability and identifying possible accommodations. A combination of the results of formal evaluation procedures, clinical narrative, and the individual’s self report is the most comprehensive approach to fully documenting impact. Documentation should be 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(s).

While relatively recent documentation is recommended in most circumstances, common sense and discretion in accepting older documentation of conditions that are permanent or non-varying is recommended. Likewise, changing conditions and/or changes in how the condition impacts the individual brought on by growth and development may warrant more frequent updates in order to provide an accurate picture. It is important to remember that documentation is not time-bound; the need for recent documentation depends on the facts and circumstances of the individual’s condition.

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

Documentation should provide information on expected changes in the functional impact of the disability over time and context. Information on the cyclical or episodic nature of the disability and known or suspected environmental triggers to episodes provides opportunities to anticipate and plan for varying functional impacts. If the condition is not stable, information on interventions (including the individual’s own strategies) for exacerbations and recommended timelines for re-evaluation is expected.

 

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

The documentation will include a description of both current and past medications, auxiliary aids, assistive devices, support services, and accommodations, including their effectiveness in ameliorating functional impacts of the disability. A discussion of any significant side effects from current medications or services that may impact physical, perceptual, behavioral or cognitive performance is helpful when included in the report. While accommodations provided in another setting are not binding on the current institution, they may provide insight in making current decisions.

 

7. Recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or collateral support services

Recommendations from professionals with a history of working with the individual provide valuable information for review and the planning process. Recommended accommodations and strategies should logically be related to functional limitations; if connections are not obvious, a clear explanation of their relationship can be useful in decision-making. While UCO has no obligation to provide or adopt recommendations made by outside entities, those that are congruent with the programs, services, and benefits offered by UCO 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.

Note: DSS reserves the right to deny services or reasonable accommodations while the receipt of appropriate documentation is pending. Students must complete the application process, submit disability documentation and bring a current concise schedule before they can receive accommodations and services.

Note: A student’s Individualized Educational Plan (IEP) will be considered as documentation when it identifies the disability along with the functional limitations. 


Full HTML Version