Documentation Guidelines

General Documentation Guidelines

Generally, for CDS to determine appropriate and reasonable accommodations, the student should submit documentation which clearly states a disability-related diagnosis and fully describes the current functional limitations that impact the student in an academic setting. Documentation, along with information obtained directly through an interactive process, serves as the basis for decision-making about a student's needs for accommodations in a challenging and competitive academic environment. Occasionally, provisional accommodations may be granted on a case-by-case basis without third-party documentation.

Documentation that is of high quality, relevant, useful, and thorough is the most helpful. The outline below has been developed to assist students in working with the treating or diagnosing professional(s) to obtain the specific information necessary to evaluate eligibility for accommodations. Students requesting accommodations for multiple disabilities may need to provide documentation for each condition.


Third-Party Documentation

Students should provide third-party documentation from a licensed or otherwise properly credentialed professional who has appropriate and comprehensive training, relevant experience and no personal relationship with the individual being evaluated. A logical connection 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). Documentation from a current treating provider should be signed and dated on letterhead and should generally include:

1. A clear diagnostic statement from a professional who is qualified to diagnose the disability.
2. The date of the diagnosis.
3. An indication of how the professional arrived at the diagnosis (e.g., clinical interview, medical history, continuous performance assessment, psychological assessment, behavior rating scales, etc.). Diagnostic tests should be based on adult norms.
4. Support for the diagnosis and how it meets the definition of a person with a disability under the ADA/504.
5. A description of how this impairment substantially limits a major life activity/activities in general and in an academic setting.
6. Relevant information relating to the impact of medication and/or treatment on the student's ability to participate in all aspects of the college's environment (classroom, housing, extracurricular activities, etc.).


Because some conditions vary, guidelines may differ from case-to-case. View documentation guidelines by disability type below for more information. We also have a disability verification form that can be used in lieu of a letter from the current treating provider.


Generally, we do not expect third-party providers to recommend specific accommodations; however, any specific recommendation for an accommodation must be supported and logically connected to the student's disability. The Center for Disability Services (CDS) will still need to address whether the request is reasonable within the higher education setting, and in some instances, may have to consult with the professor or department to determine whether the requested accommodation would result in a fundamental alteration.


Documentation Checklist

For a more seamless process, please consider the following:

1. Ensure the document formatting is properly oriented and readable.
2. Ensure the document includes a date.
3. Verify that all necessary signatures are included on the document.
4. Submit the document in a format that cannot be edited to prevent unauthorized changes.
5. If the document is password-protected, provide the office with the password or encryption key.


Insufficient Documentation

Occasionally, provisional accommodations may be granted on a case-by-case basis without third-party documentation. However, in most circumstances documentation from a third-party professional will be necessary to support eligibility and determine appropriate accommodations. CDS has the discretion to require additional documentation if it is determined that the existing documentation/information is incomplete or inadequate to ascertain the existence of a disability or the need for accommodation.

A general statement of symptoms or difficulties is often insufficient. CDS does not interpret a diagnosis or the current impact and/or functional limitations from documentation; therefore, the following materials alone are generally insufficient to determine eligibility:

  • Official medical records, medical chart notes or prescription pad notations; 

  • High school IEPs, 504 plans, and/or SOPs not accompanied by disability documentation are typically considered insufficient documentation. 

  • Documents prepared for specific non-educational venues (e.g. SSA, hospital discharge documents, letters written for off-campus housing considerations, etc.).

CDS has the discretion to require additional documentation if the existing documentation is incomplete or inadequate to determine the existence of a disability or the need for accommodations.


Records of Past Accommodations

CDS will consider records of past accommodations when evaluating a current request for accommodation. Past information is often helpful to develop an understanding of how conditions are likely to impact the student. However, additional current documentation is also needed in many situations. Past records may include, but are not limited to:

  • A description of the student’s needs. 

  • Records of past accommodations and services from high school or another college/university. 

  • Psychological or medical evaluations from childhood. 

  • Letters from past health, education or service providers. 

  • A Summary of Performance (a document prepared between the high school and the student in transition planning) is generally not considered acceptable documentation in and of itself. 

Any past documentation submitted should be signed and dated on letterhead and completed by a qualified professional (e.g. medical doctor, psychologist, counselor).

 

Note: Licensing Exams

Board, licensing, and third-party testing agencies such as ETS, USMLE, and state bar associations often require more extensive documentation than the Center for Disability Services at College of Charleston for accommodations. Check with each testing agency for specific documentation requirements to ensure there is time to obtain additional testing, if needed.

Disability-Specific Documentation Guidelines

In this section, you'll find disability-specific documentation guidelines.
  • Attention Deficit/Hyperactivity Disorder (AD/HD)

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A clear diagnostic statement from a professional who is qualified to diagnose ADHD: Licensed psychologist or neuropsychologist, licensed school psychologist, psychiatrist, physician (M.D.) specializing in the diagnosis and treatment of attention deficits. 
    • The date of the diagnosis. 
    • An indication of how the professional arrived at the diagnosis (clinical interview, medical history, continuous performance assessment, psychological assessment, behavior rating scales, etc.). 
    • Support for the diagnosis and how it meets the definition of a person with a disability. 
    • A description of how this impairment substantially limits a major life activity/activities in general and in an academic setting. 
    • Relevant information regarding executive functioning including memory, concentration, attention and discussion of strengths and impact of condition(s) in the postsecondary environment.
    In lieu of a report, your treatment provider can complete the Disability Verification Form.
  • Autism Spectrum Disorder (ASD)

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A diagnosis from a licensed psychologist, psychiatrist, developmental pediatrician or neurologist qualified to diagnose ASD.
    • Evidence of a comprehensive diagnostic evaluation.
    • Support for the diagnosis and how it meets the definition of a person with a disability.
    • The date of the assessment, interpretation of data, history and observations. 
    • Historical perspective of academic adjustments. 
    • A description of how this impairment substantially limits a major life activity/activities in general and in an academic setting. 
    • May also include relevant information relating to the impact of medication and/or treatment on the student’s ability to participate in all aspects of the College environment. 
    In lieu of a report, your treatment provider can complete the Disability Verification Form.
  • Deaf or Hard of Hearing (HOH)

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A clear diagnostic statement from a professional who is qualified to make such a diagnosis:  Otorhinolaryngologists (ENT), Otologists, Audiologists. 
    • Test data, interpretation of data, history and observations. 
    • Relevant information relating to the impact of the disability on the student’s ability to participate in all aspects of the College environment (classroom, housing/dining, extracurricular activities, etc.). 
    In lieu of a report, your treatment provider can complete the Disability Verification Form.
  • Learning Disabilities

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A diagnosis from a licensed psychologist or neuropsychologist, licensed school psychologist, or other treating provider who is qualified to diagnose a learning disability. 
    • Evidence of a comprehensive diagnostic evaluation. 
    • Assessment date, interpretation of data, history and observations. 
    • A detailed statement about how the student’s academic achievement including reading, writing, math, oral language is substantially impacted as well as any other aspects of the College environment.
    • Information regarding information processing/cognitive abilities including speed of processing, cognitive efficiency, visual-auditory processing, perceptual-motor processing, etc. and discussion of strengths and impact of condition(s) in the postsecondary environment
    • Information regarding executive functioning including memory, concentration, attention and discussion of strengths and impact of condition(s) in the postsecondary environment
    • A detailed statement about how the student’s education is substantially impacted as well as any other aspects of the University environment.
    • Information regarding language abilities including expressive-receptive language, speech, and discussion of strengths and impact of condition(s) in the postsecondary environment
    • Historical perspective of academic adjustments. 
  • Other Medical Conditions

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A clear diagnostic statement from a professional who is qualified to make such a diagnosis:  licensed neuropsychologist, primary care physician, physician (M.D.) specializing in diagnosis and treatment of this medical condition. 
    • Test data, interpretation of data, history and observations. 
    • Support for the diagnosis and how it meets the definition of a person with a disability. 
    • A description of how this condition substantially limits a major life activity/activities in general and in an academic setting. 
    • Relevant information relating to the impact of medication and/or treatment on the student’s ability to participate in all aspects of the College environment. 

    An annual update may be requested. 

    In lieu of a report, your treatment provider can complete the Disability Verification Form.
  • Psychological/Psychiatric Disorders

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A diagnosis from a licensed psychologist, psychiatrist, licensed professional counselor, clinical social worker, or psychiatric nurse practitioner.
    • The disability with an AXIS diagnosis and/or DSM code.
    • Support for the diagnosis and how it meets the definition of a person with a disability.
    • A description of how this impairment substantially limits a major life activity/activities in general and in an academic setting.
    • Relevant information relating to the impact of medication and/or treatment on the student’s ability to participate in all aspects of the College environment (classroom, housing/dining, extracurricular activities, etc.). If specific accommodations are being requested by the student, CDS may request that the treating provider specifically indicate that those accommodations, if approved, would not be counter to the treatment plan. 

    In lieu of a report, your treatment provider can complete the Disability Verification Form.

    An annual update may be requested. 

  • Traumatic Brain Injury (TBI)/Concussion

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A diagnosis from a licensed neuropsychologist, primary care physician, physician (M.D.) specializing in the diagnosis and treatment of TBI
    • Information on the type of acquired/traumatic head injury
    • Information on cognitive ability including discussion of strengths and impact of condition(s) in the postsecondary environment
    • Information on speech, language and communication ability including discussion of strengths and weaknesses
    • Information on executive functioning including memory, concentration, attention and discussion of strengths and impact of condition(s) in the postsecondary environment
    • Information on academic achievement including reading, writing, math, oral language and discussion of strengths and impact of condition(s) in the postsecondary environment

    In lieu of a report, your treatment provider can complete the Disability Verification Form.

  • Visual Impairments

    Documentation from a current treating provider should be on letterhead, be signed and dated, and should include:

    • A clear diagnostic statement from a professional who is qualified to make such a diagnosis:  Ophthalmologist, Optometrist.
    • Test data, interpretation of data, history and observations. 
    • Relevant information relating to the impact of the disability on the student’s ability to participate in all aspects of the College environment. 

    In lieu of a report, your treatment provider can complete the Disability Verification Form.