Documentation Guidelines

Guidelines for Documentation of Students with Attention Deficit/ Hyperactivity Disorders (AD/HD)

Students seeking services from Santa Fe College Disabilities Resource Center (DRC) on the basis of Attention Deficit/Hyperactivity Disorders (AD/HD) must submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Protection under these statutes is based upon documentation of a disability that currently substantially limits some major life activity including learning.

Documentation must be provided by a developmental pediatrician, neurologist, psychiatrist, licensed doctoral-level clinical allied health professional, educational psychologist, or a combination of such professionals with expertise in the diagnosis of attention deficit disorder in adults. The diagnosis must be current, within the past three years.

The following guidelines are provided in the interest of ensuring that the documentation is complete and appropriate. The documentation should include:

• Clear statement of the DSM V diagnosis.
• Summary of procedures and instruments used to make the diagnosis.
• A summary of evaluation results, including standardized scores when available.
• A history of past and present symptoms which meet the criteria for diagnosis.
• Medical history relating to current use of medication and the impact of the medication on the student's ability to meet the demands of an academic program.
• Statement of functional limitations and the expected impact on student's academic performance.
• Recommendations for academic accommodations to help compensate for the disability.

Appropriate reasonable accommodations and services are individually determined by the Disabilities Resource Center staff in consultation with the student on the basis of the information provided in the documentation.

Guidelines for Documentation of Students with Physical and/or Other Health Disorders

In conformance with the regulations of the Americans with Disabilities Act of 1990 (ADA) and the Rehabilitation Act of 1973, as revised, Santa Fe College (SF) will make reasonable modifications to its policies and practices and will provide certain individualized services and accommodations as needed to assure nondiscrimination on the basis of disability. This policy sets forth SF's current minimum requirements for documentation of the above disabilities.

Students or applicants for admission who would like to request disability-related services and accommodations are invited to apply in person at the Disabilities Resource Center (DRC) in Building S, Room 229. As a part of the application process, DRC staff will require documentation of the disability. This documentation must have been prepared by a person who is not a family member of the student and who is qualified by professional training and practice to diagnose and treat the impairment leading to the disability. It must also 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 will not be accepted.

Documentation will include:

1. Diagnosis
2. Limitations
3. Recommendations

Eligibility will be determined on the basis of the presence of a disability and a need for services and accommodations to support an equal educational opportunity. Information from the disability documentation, the student's stated experience with services and accommodations that have been effective in the past, and DRC professional judgment will be drawn upon in making the eligibility determination.

The legal definition of disability includes:

1. a physical or mental impairment which
2. substantially limits one or more of the major life activities of the person in question.

According to the ADA, major life activities include but are not limited to walking, breathing, seeing, hearing, performing manual tasks, caring for one's self, learning, and working. Thus, disability has both medical and functional elements, and both of these elements must be explicitly documented for DRC eligibility purposes. A doctor's statement that a student has MS, CP, or schizophrenia, for example, would only indicate the diagnosis (or name) of the impairment. Further written information is necessary to indicate how this impairment substantially limits one or more of the major life activities of the student. If the student is taking prescription medicine that has known side effects on major life activities, this should be reported as well; for example, the effects of psychotropic medications on concentration and cognitive functioning.

Timeliness

Though applications will not be refused by DRC on the basis of untimeliness, it is strongly recommended that those who would like to apply for or renew services and accommodations not delay contacting DRC until the first few weeks of the semester or just prior to exams. Your first contact should be made immediately after you register for classes for the coming semester, and you must follow-up with any necessary instructions given by DRC staff. Since services are arranged on a first-come first-served basis, unfortunate delays often result when applications are untimely.

Guidelines for Documentation of a Psychiatric/Psychological Disorder

Students who are seeking support services from the Santa Fe College Disabilities Resource Center (DRC) on the basis of a diagnosed psychiatric/psychological disorder are required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Protection under these civil rights statutes is based upon documentation of a psychiatric/psychological disorder that currently substantially limits some major life activity including learning.

The following guidelines are provided in the interest of assuring that documentation is appropriate to verify eligibility and support requests for reasonable accommodations, academic adjustments and/or auxiliary aids on the basis of a psychiatric/psychological disorder that substantially limits one or more major life activities. The Coordinator of the DRC is available to consult with diagnosticians regarding any of these guidelines.

• A DSM V Multiaxial Diagnosis: a thorough explanation of diagnoses including symptomology and plan for treatment must be included. There must be clear and specific evidence of the disorder(s) in question. A listing of the functional limitations imposed by the disorder and how they might impair the student’s ability to perform to his/her potential in an academic setting must also be included. Diagnoses must be current. Diagnoses made prior to six months before the present date are not acceptable unless the disorder is considered to be relatively stable and long-standing.
• A description of any accommodation and/or auxiliary aid that has been used at the secondary or postsecondary level must be discussed. Include information about the specific conditions under which the accommodation was used (e.g., standardized testing, final exams) and whether or not it benefited the student. If no accommodations have been previously provided, a detailed explanation as to why none has been used and the rationale for the student’s currently needing accommodation(s) must be provided.
• Provide a complete list of psychoactive medications the student is taking including dosage levels and any likely side-effects. If the names of other medications the student is currently taking are available, they too should be included.
• Professionals providing psychological diagnoses and treatments must be qualified to do so. Experience in working with the adult population is essential. Diagnostic reports must include the names, titles, and professional credentials (e.g., Licensed Psychologist) of the professional providing the diagnostic report. Date of diagnosis must also be included.

Documentation Guidelines for Sensory Impairments (Hearing, Vision)

Documentation of a disability is necessary for a student to establish their eligibility for academic adjustments, auxiliary aids and services while at Santa Fe College. The following documentation requirement complies with Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Amendments Act. The Disabilities Resource Center requires a student, who self-identifies as having a disability, to provide current (i.e. within the last three years) and comprehensive documentation that verifies a chronic disabling disorder and identifies functional impairments arising from that disorder. The confidentiality of all documents submitted to the Disabilities Resource Center are protected under the Family Educational Rights and Privacy Act (FERPA). This paper sets forth Santa Fe College's requirements for documentation necessary for those students with sensory impairments.

Documentation

Those students who wish to request disability-related accommodations and services are invited to apply in person at the Disabilities Resource Center (DRC) in Building S, Room 229. As a part of the process, DRC staff will require documentation of the disability. Documents must have been prepared by a person who is not a family member of the student and who is qualified by professional training and practice to diagnose and treat those impairments associated with the disability. Documents 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 will not be accepted.

The documentation should include:

• Clear statement of the diagnosis with relevant procedures and instruments used to make the diagnosis as well as a summary of evaluation results when available.
• Medical history relating to current functional limitations and the expected impact on student's academic performance including current use of medication and the impact of the medication on the student's ability to meet the demands of an academic program. In cases for students with a hearing impairment, a copy of most recent audiogram and any evaluations conducted are beneficial.
• Diagnosis must be current, within the past three years.
• Recommendations for reasonable academic accommodations to help neutralize the disability in question.

Eligibility

Eligibility will be determined on the basis of the presence of a disability and a need for services and accommodations to support an equal educational opportunity. Information from the disability documentation, the student's stated experience with services and accommodations that have been effective in the past, and DRC professional judgment will be drawn upon in making the eligibility determination.

The legal definition of disability includes:

A physical or mental impairment which substantially limits one or more of the major life activities of a person, including learning. According to the ADA, major life activities include but are not limited to walking, breathing, seeing, hearing, performing manual tasks, caring for one's self, learning, and working. Thus, disability has both medical and functional elements, and both of these elements must be explicitly documented for DRC eligibility purposes.

Sensory Impairments Defined

According to the documentation provided by the Florida College System Disabled Classification, hearing and visual impairments are defined by the following classifications:

• Hearing impairment
  A hearing loss of 30 decibels or greater, pure tone average of 500, 1000, 2000, 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.
• Visual impairment
  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, the following: cataracts, glaucoma, nystagmus, retinal detachment, retinitis pigmentosa, and strabismus.

Guidelines for Documentation of a Specific Learning Disorder

Students seeking services from Santa Fe College Disabilities Resource Center (DRC) on the basis of a diagnosed specific learning disorder must submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Protection under these statutes is based upon documentation of a learning disorder that currently substantially limits some major life activity including learning.

The following guidelines are provided in the interest of assuring that documentation is appropriate to verify eligibility and support requests for reasonable accommodations, academic adjustments, and/or auxiliary aids on the basis of a learning disorder.

• Testing must be comprehensive. It is not acceptable to administer only one test for the purpose of diagnosis. Minimally, domains to be addressed must include (but not be limited to):
  • Aptitude
    The Wechsler Adult Intelligence Scale - Revised (WAIS-R) with subtest scores is the preferred instrument. The Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability, or the Stanford-Binet Intelligence Scale: Fourth Edition are acceptable.
  • Achievement
    Current levels of functioning in reading, mathematics and written languages are required. Acceptable instruments include the Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Achievement; Wechsler Individual Achievement Test (WIAT); Stanford Test of Academic Skills (TASK); Scholastic Abilities Test for Adults (SATA); or specific achievement tests such as the Test of Written Language - 2 (TOWL-2), Woodcock Reading Mastery Tests - Revised, or the Stanford Diagnostic Mathematics Test. The Wide Range Achievement Test - Revised (WRAT-R) is NOT a comprehensive measure of achievement and therefore is not suitable.
  • Information Processing
    Specific areas of information processing (e.g., short- and long-term memory; sequential memory; auditory and visual perception/processing; processing speed) must be assessed. Information from subtests on the WAIS-R or the Woodcock-Johnson Tests of Cognitive Ability as well as other instruments relevant to the presenting learning problem(s) may be used to address these areas. This is not intended to be an exhaustive list or to restrict assessment in other pertinent and helpful areas such as vocational interests and aptitudes.
• Testing must be current. In most cases, this means testing that has been conducted on an adult scale. Because the provision of all reasonable accommodations and services is based upon assessment of the current impact of the student's disabilities on academic performance, it is in a student's best interest to provide recent and appropriate documentation.
• There must be clear and specific evidence and identification of a learning disorder (DSM V Diagnosis). Individual "learning styles" and "learning differences" in and of themselves do not constitute a learning disorder.
• Actual test scores must be provided. Standard scores and/or percentiles are acceptable; grade equivalents are not acceptable unless standard scores and/or percentiles are also included. This is important since certain college policies and procedures (e.g., petitioning for permission to substitute courses) require actual data to substantiate eligibility.
• Professionals conducting assessment and rendering diagnoses of specific learning disorders must be qualified to do so. Trained and certified and/or licensed psychologists, learning disorder specialists, and educational therapists are typically involved in the process of assessment. Experience in working with an adult population is essential.
• Tests used to document eligibility must be technically sound (i.e., statistically reliable and valid) and standardized for use with an adult population.
• Diagnostic reports must include the names, titles, and professional credentials (e.g., licensed psychologist) of the evaluators as well as the date(s) of testing. All reports must be typed.
• A written summary of or background information about the student's educational, medical, and family histories related to the learning disorder must be included.
• A description of any accommodation and/or auxiliary aid that has been used at the secondary or postsecondary level must be discussed. Include information about the specific conditions under which the accommodation was used (e.g., standardized testing, final exams) and whether or not it benefited the student. If no accommodations have been previously provided, a detailed explanation as to why none has been used and the rationale for the student's currently needing accommodation(s) must be provided.

Guidelines for Documentation of a Traumatic Brain Injury and Neurocognitive Disorders

Students seeking services from Santa Fe College Disabilities Resource Center (DRC) based upon a diagnosed traumatic brain injury (TBI) or neurocognitive disorders (cerebrovascular accidents, tumors, anoxia, toxic injuries, infections, degenerative diseases etc.) must submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. The basis for protection under these statutes is documentation of a TBI or neurocognitive disorders that currently and substantially limits some major life activity including learning.

The following guidelines are provided in the interest of assuring that documentation is appropriate to verify eligibility and support requests for reasonable accommodations, academic adjustments, and/or auxiliary aids on the basis of a TBI or neurocognitive disorders. The Coordinator of the DRC is available to consult with diagnosticians regarding any of these guidelines.

• Neuropsychological assessments or medical reports must be comprehensive. For making a diagnosis, it is not acceptable to administer only one test. Documentation should address but not be limited to:
  • Brain/Behavior Functions: Intellectual functioning, executive function, attention/concentration, visuospatial processing, language processing, verbal learning/memory, visual learning/memory, processing speed/style, sensory perceptual functions, motor speed/strength, academic skills, and emotional status. Data should include subtest scores and percentiles.
  • Evidence of Current Impairments: Evidence that current symptoms and behaviors significantly impair the individual's brain-behavior functions.
  • Facts from Diagnostic Interview: The interview must contain self-report and third-party information pertaining to developmental history, family history, learning or psychological difficulties, relevant medical history, and a thorough academic history.
  • Evidence that rules out alternative diagnoses or explanations. The assessment must investigate and discuss the possibility of dual diagnoses and alternative or coexisting mood, learning, behavioral, and/or personality disorders that may confound the diagnosis.
  • Clinical summary that indicates the substantial limitations to major life activities posed by the functional impairments and describes the extent to which these limitations would adversely influence the academic environment for which the individual anticipates seeking accommodations. A summary should also suggest how the specific effects of the limitations might be accommodated, and state how they are mediated by the recommended accommodations. It is not enough to state generally that a physical/medical condition may cause learning difficulties.
  • Further assessment by an appropriate professional may be required if co-existing disabling conditions are indicated.
• Assessment must be current. In most cases, this means assessments conducted within the past three years. Because the assessment of the current effects of the student's impairments on academic performance is the basis for providing all reasonable accommodations and services it is in a student's best interest to provide recent and appropriate documentation.
• There must be clear and specific evidence and identification of a traumatic brain injury or neurocognitive disorders (DSM V or ICD-International Classification of Diseases). Actual test scores must be provided. Standard scores and/or percentiles are acceptable; grade equivalents are not acceptable unless standard scores and/or percentiles are also included. This is important since certain college policies and procedures (e.g., petitioning for permission to substitute courses) require actual data to substantiate eligibility.
• Professionals conducting assessments and rendering diagnoses of TBI or other neurocognitive disorders must be qualified to do so. Trained, certified, and/or licensed physicians, neurologists, clinical psychologists, rehabilitation psychologists, neuropsychologists, or psychiatrists are typically involved in neuropsychological assessments. Experience in working with an adult population is essential.
• Tests used to document eligibility must be technically sound (i.e., statistically reliable and valid) and standardized for use with an adult population.
• Diagnostic reports must include the names, titles, and professional credentials (e.g., licensed neuropsychologists) of the evaluators as well as the date(s) of testing. All reports must be typed.