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Guidelines for Documentation

Guidelines for Assessment and Documentation

Westminster College seeks to provide equal access in higher education to academically qualified students with physical, learning, and psychiatric disabilities. Disability Services (DS) works with departments throughout the college to help ensure that programs and facilities are accessible to all members of the college community.

Disability means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of such individual; a record of such impairment; or being regarded as having such an impairment (including but not limited to: seeing, hearing, walking, learning disabilities, mental illness, etc.)

Students with a qualifying disability may be eligible, under the Americans with Disabilities Amendments Act of 2008 (ADAAA) and/or Section 504 of the 1973 Rehabilitation Act, for reasonable accommodations that will support equal opportunity and inclusion in college programs and services.

Documentation from a credentialed examiner may be requested to substantiate the presence of a possible disability and to establish the possible need for accommodations at Westminster College. These guidelines are summarized below.

Westminster College’s Essential Elements of Quality Documentation

  1. All documentation must be provided on official letterhead of the professional describing the disability and include the assessment date, as well as, the signature of the evaluator.
  2. The evaluator must be licensed or credentialed evaluator, with specific training or expertise related to the condition begin diagnosed, and who is not related to the individual. (ex. hearing disability diagnosed by certified Audiology (CCC-A) or by an Ear, Nose, & Throat M.D.)
  3. Each documentation provided must include the name, title, and professional credentials of the evaluator, including information about their license or certification.
  4. Definition of current documentation: general standard is within four (4) years but see specific disability for more specific standards.

Included in the documentation should be at least two (2) of the following.

  • Clear diagnostic statement, including diagnostic sub-types where relevant, that describes how the condition was diagnosed and provides information on the functional impact of the condition. A full clinical description will convey this information, as will diagnostic codes from the DSM (Diagnostic Statistical Manual of the American Psychiatric Association) or the ICF (International Classification of Functioning, Disability and Health of the World Health Organization.)
  • Description of the diagnostic methodology used; including diagnostic criteria, evaluation methods, tests and dates of administration, clinical narrative, observations, and results. Diagnostic methods must be congruent with the particular disability and with current professional practices in the field.
  • Description of the current functional limitations of the disability condition helps establish the possible disability and identify possible accommodations. A combination of the individual's self-report, results of formal evaluation procedures, and clinical narrative are recommended. Quality documentation will demonstrate how a major life activity is significantly, amply, or substantially limited by providing evidence of frequency and pervasiveness of the condition(s).
  • Description of the progression or stability of the disability over time and in context.
  • Description of current and past accommodations, services or medications.
  • Recommendations for accommodations, assistive devices, assistive services, compensatory strategies, and/or collateral support services.

Insufficient documentation can result from one or more of the following.

  • Out dated documentation with insufficient information
  • Documentation developed by a relative
  • Inappropriate professional making the diagnosis
  • No diagnosis given
  • For a Learning Disability or Attention Deficit Disorder, no IQ test data or no achievement test battery (with scores) administered to support the diagnosis administered to support the diagnosis
  • Average range of test scores (having no scores representing a significant limitation)
  • An unsigned report
  • Report not written on evaluator's letterhead
  • No functional limitations identified (for instance, how the diagnosis affects the student and how it relates to the accommodation request)
  • Diagnosis based upon one subtest score with no addition support

Please Note

An Individual Education Plan (IEP) or 504 Plan form high school will not meet the documentation guidelines alone. A physician's letter or note alone is not sufficient to document Attention Deficit Disorder (ADD), nor can prescribed medication be used to document a disability. In general, please know it is not acceptable for such documentation to include a diagnosis or testing performed by a member of the student's family.

The Americans with Disabilities Amendment Act of 2008 broadened the definition of disability in the number and types of conditions that could be considered. The new law also strengthened the importance of quality, detailed documentation in determining who is eligible for accommodations. Many conditions may now be considered a disability, but in order to qualify for accommodations, a major life function must be significantly, amply or substantially limited in the college environment.

Specific graduate, professional, and/or licensure testing (i.e. GRE, LSAT, NCLEX) may require more up-to-date documentation. Each testing agency provides a description of the required documentation. Accommodation approval from Westminster College does not guarantee accommodation with these testing providers.

All determinations for accommodations and disability eligibility are made on a case-by-case basis by the staff in Disability Services in consultation with the individual student.