Documentation Guidelines for a Learning Disability

Every report submitted to the Office of Disability Services (ODS) for learning disability documentation must meet the ODS general documentation guidelines as well as including the following elements:

I.   Recent Assessment

The report must provide adequate information about the student’s current level of functioning.  If such information is missing and/or outdated, the student may be asked to provide a more recent or complete assessment. Recent documentation:

• Reflects current functioning: 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 of a condition.
• Relatively recent documentation is recommended; there is discretion in accepting older documentation of disabilities that are permanent or non-varying. 
• Changes in the functional impact of a condition (e.g., result of growth, development, changes in symptomatology) may warrant more frequent updates in documentation.
• The necessity of recent documentation may depend on the facts and circumstances of the student’s disability and the accommodations requested.

For more information on recency of assessments, review the ODS General Documentation Guidelines, specifically the section on Current Functioning and Need for Current Documentation.

II.   Neuropsychological and/or Psycho-educational Testing

There should be a discussion of all tests that were administered and observations of the student’s behavior during testing.  Actual test scores must be provided. Standard scores are required; percentiles and grade and age equivalents are not acceptable unless standard scores are also included. In addition to actual test scores, interpretation of results is required. Test protocol sheets or scores alone are not sufficient; some form of narrative must accompany scores. If time constraints for exams are an issue, tests should be administered both timed and untimed and scores for both testing conditions should be reported. Non-standardized, non-normed measures (such as informal reading inventories or writing samples) may supplement standardized testing, but are insufficient documentation by themselves.  

IEP's and 504 Plans:

Please note that Independent Educational Plans (IEP’s) and/or 504 plans were developed for secondary education and may not provide the necessary testing, diagnostic information, or information related to determining reasonable accommodations in higher education.  However, some IEP's and 504 plans may provide very useful information that could be used in the process of evaluating reasonable accommodations in higher education.  If a student is confused about whether or not former records include the appropriate testing required, please contact the Office of Disability Services. If submitting IEP’s or 504 plans, please only submit the most recent versions.

A. Diagnostic Interview Summary

The interview should focus upon the student’s developmental and educational history, including any persistent academic or emotional problems.  Comorbid conditions should be discussed and there should be a statement explaining whether the learning disability or the other condition is the primary diagnosis.  

B. Neuropsychological and/or Psycho-educational Tests Required:

Tests used to document eligibility must be normed, standardized, and otherwise technically sound (i.e., statistically reliable and valid) and should be standardized for use with an adult population, appropriate tests include:

Aptitude Tests:

• Aptitude testing (also known as “tests of cognitive ability,” intelligence testing,” “IQ testing” or a “psychological evaluation”) – examples include the Wechsler Adult Intelligence Scales (WAIS) and the Woodcock-Johnson-IV - Tests of Cognitive Ability.

Academic Achievement Tests:

• Academic achievement testing (sometimes called an “educational evaluation” or “academic testing”) – examples include the Wechsler Individual Achievement Test III (WIAT III), the Woodcock-Johnson-IV - Tests of Achievement. Screening assessments or brief batteries do not constitute a complete measure of achievement.
   

If applicable, additional supplemental tests such as:

• Nelson-Denny Reading Test for both normal and extended time conditions
• Test of Written Language - 4
• Woodcock Reading Mastery Tests – Revised
• Wide Range Achievement Test 5 (WRAT5)

C.  Clinical Summary, Recommendations, Accommodations and Diagnosis:

1. Clinical summary: The clinical summary should integrate the elements of the battery with background information, observations of the client during the testing situation.

2. Recommendations: The recommendations should explain how the student’s performance demonstrates a need for accommodation(s) at the post-secondary level.  This report should present evidence of a substantial limitation to learning and explain how the patterns of strength and weakness are sufficiently significant to substantiate a learning disability diagnosis. 

3. Accommodations: The rationale for a recommended accommodation as expressed in the assessment report must be clear and convincing as to the necessity of the accommodations to achieve equal access. Further, reasonable adjustments, support services, and auxiliary aids are those which: do not constitute fundamental alteration of the nature of the course or of essential course requirements; do not cause undue administrative or financial burden to the university in effecting implementation; and are not items or services of a personal nature. For further information refer to the Supported Need for Requested Reasonable Accommodations.

4. Rule Out other Factors: the report should demonstrate that the evaluator has ruled out alternative explanations for the learning problem.  Individual "learning styles" and "learning differences" in and of themselves do not constitute a learning disability. If social or emotional factors are believed to contribute to the pattern of observed scores, they should be discussed.

5. Diagnosis: The report must clearly state a diagnosis of a learning disorder (The components of and criteria for a diagnosis of learning disorders are outlined in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS – Fifth Edition (DSM-V).