Documentation Details

Documentation is information from an appropriately qualified health or other service professional who is knowledgeable about the student’s condition. This professional might be a therapist, doctor, rehabilitation counselor, audiologist, nurse practitioner, or mobility specialist. Documentation can vary in length and format, but should focus on the ways the condition currently affects the student, especially in an academic environment. Documentation on file needs to be current within three years.

The Accessibility Services staff uses documentation to better understand a student’s experience of their condition, identify impacts in an academic setting, and make informed decisions to determine reasonable and appropriate accommodations.

Documentation must reflect that the condition substantially limits a major life activity or major bodily function. Changing conditions and/or changes in how a condition impacts the individual may warrant more frequent updates. Generally, sufficient documentation includes: a psychological/psycho-educational evaluation or a letter from medical/mental health provider which includes:

  • Qualifications of Provider. Documentation must be provided on the clinician's office or practice letterhead and must be dated and signed by a professional who is licensed or certified in the area for which the diagnosis is made. The letter must include the provider's name, title, and license/certification credentials. The provider may not be a member of the student's or applicant's family or otherwise have a close personal relationship to the student or applicant.

  • Diagnosis and History. Documentation must include a diagnostic statement identifying the disability and ideally the ICD or DSM classification along with any relevant personal, psychosocial, medical, developmental, and educational history.

  • Description of Diagnostic Methodology. Documentation must include a full description of the diagnostic methodology used, including data and measurements from appropriate evaluation instruments. The results obtained should draw a direct link from the diagnosis to the functional limitations of the disability.

  • Current Impact and Functional Limitations. Documentation must include a clear description of the current impact and functional limitations of the condition pertaining to the academic, workplace, or residential settings. The provider should describe whether symptoms are constant or episodic, as well as the frequency and/or duration of those symptoms. The provider should also specify any treatments, medications, services, or assistive technology that has been prescribed or that is in use and also describe their mediating effects and potential side effects.

  • Recommendations. Documentation should include the provider's academic accommodation recommendations, that should be directly linked to the impact or functional limitations associated with the disability or to medications or treatments prescribed to control symptoms. Please note that Accessibility Services welcomes and considers academic accommodation recommendations from medical professionals but that Accessibility Services will make the ultimate determination regarding reasonable and appropriate academic accommodations.

If the documentation provided does not contain sufficient information for the Accessibilities Services staff to determine whether an accommodation is necessary, the student/parent/guardian will be informed of the insufficiency and additional documentation may be requested.

Please also note that Accessibility Services will not interpret a diagnosis or infer the current impact or functional limitations described in documentation. Because they typically include only information about a student's or applicant's prior academic accommodations rather than specific information about the student's limitations, the following materials, standing alone without explicit reference to the effect of a diagnosis upon current functioning, are generally insufficient for determining a student's or applicant's eligibility for academic accommodations:

  • Medical records, medical chart notes, or prescription pad notations.

  • High school IEPs or 504 Plans.

  • Disability-related documents prepared for other agencies (e.g., Social Security Administration documentation).

For a list of local providers of PsychoEducational Evaluations, please contact Durham- or Morganton-