Medical Documentation

Medical Documentation

This information is intended to provide the minimum standards for submitting documentation to the Office of Disabilities. These guidelines assist the office in determining reasonable accommodations for individuals with physical disabilities. There are three components to submitting documentation on the basis of a physical disability: Qualified professional, Current, and Comprehensive. See descriptions below for a detailed explanation of each component.

Physical disabilities include but are not limited to impairments, chronic illnesses, traumatic brain injury, and visual, hearing, mobility, and manual limitations. When these occur in combination with attentional, psychiatric, and/or learning disorders, relevant information pertaining to these latter diagnoses as it applies to the specific learning environment must be included. Major life activity: Examples of major life activities include walking, sitting, standing, seeing, hearing, speaking, breathing, learning, working, caring for oneself, and performing manual tasks.


Professionals conducting assessments and rendering physical diagnoses must be qualified in the specific area for which they are making recommendations. A qualified professional must have (1) comprehensive training and relevant expertise in the specialty and (2) appropriate licensure/certification. Professionals such as physicians, surgeons, optometrists, audiologists, occupational and physical therapists, neurologists, and other health and learning specialists, must provide documentation within their areas of expertise. Professionals should utilize the most recent evaluation tools available in the profession. Professionals who render a diagnosis outside of their area of expertise will not be considered in support of an accommodation. Comprehensive documentation may include reports from several professionals or a team. Evaluations and diagnoses from family members, even when the family member is a qualified professional, will not be accepted for professional and ethical reasons.

All documentation must include the name, title, and credential of the professional completing the report or evaluation. The report must be in English, typed, and on professional letterhead. The documentation should include current contact information for the professional. All reports/evaluations must be signed by the professional and include information about the license or certification of the professional, area of specialization, employment, and the state in which the individual practices.

Documentation submitted must have been completed within the

  • past three years for learning disabilities
  • past six months for medical disabilities
  • past six months for ADHD
  • past six months for psychological disabilities
Reasonable accommodations are determined based on the current functioning of the individual. This cannot be determined without recent documentation. All instruments used by an examiner must be the most recent version at the time of testing to be considered current. Discretion by the director may be used in accepting documentation for some permanent conditions. In cases where the disability is long-term, comprehensive documentation may be submitted that is older but a recent evaluation update by the treating professional is required. For example, the diagnosis of Tourette's syndrome may have occurred in childhood. In this case, documentation should be submitted from the initial diagnosis as well as a report from a qualified professional documenting the current symptoms, levels of functioning, treatment, and medications. The update should address the current levels of functioning and all components listed under comprehensive documentation for the specific disability. Moreover, reports and/or evaluations should specifically address limitations or impairments related to the academic environment. Reasonable accommodations are based on the current impact of the disability and not the potential impact of the disability or the possibility of experiencing symptoms related to a disability, medication, or treatment. It is imperative that professionals be detailed and explicit when describing the current functioning of the individual.


Medical documentation should be based on a comprehensive diagnostic, clinical, or other evaluation. This evaluation should include the appropriate tests, measures, or assessments, and the written results of each evaluation. In addition, a comprehensive report should include a history of presenting symptoms, date of onset, duration and severity of the disorder. It must also include relevant developmental and historical data. The diagnostic report/evaluations should include the following components:
  1. A specific diagnosis. Doctors and professionals should identify the tests, measures, or assessments used to determine the diagnosis and clearly outline the results of their evaluation. Professionals should identify a description of the current symptoms, the duration of the symptoms, and the severity of the symptoms or limitations. Language that lists all of the potential symptoms without addressing the specific condition of the individual may not be justification for an accommodation. A description of current functional limitations as it applies to the academic environment. The description should include medical information describing the degree to which the current functional limitations restrict the condition, manner, or duration under which the student can perform a major life activity. It is imperative that professionals be detailed and explicit when describing the current functioning of the individual.
  2. Information regarding any medications that may impact academic performance. Many individuals often benefit from pharmacological treatments or therapies; however, this alone does not justify the need for an accommodation.
  3. Information relevant to the impact on the individual's performance within the current academic environment. A prior history of accommodations, without demonstration of current need, does not in and of itself warrant the provision of accommodations.
  4. Evidence that alternative explanations for the limitation have been considered and ruled out as appropriate. For example, alternative explanations may include substance abuse, medication effects, and motivational factors affecting performance/functioning.
  5. A rationale for each accommodation. The medical professional should describe (1) the degree of impact of the disorder on a specific major life activity, and (2) the degree of impact on the individual. There must be a clear link between the accommodations and the functional limitations of the individual that directly applies to the academic environment.
  6. Accommodations that result in a fundamental or substantial alteration of the nature of the educational program and are not reasonable as a matter of law and will, therefore, not be granted.

Please contact the Office of Disability Services should you have any questions.

Office of Disability Services
Phone: (305) 284-2374 
Fax: (305) 284-1999