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Documentation Guidelines

Under the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, individuals with disabilities are protected from discrimination and assured services. In order to establish that an individual is covered under the ADA, the documentation must indicate that a disability currently exists and it substantially limits some major life activity, including learning.

In most cases, an IEP, 504 Plan or brief note from a physician does not contain the information outlined in the points below, so is not sufficient as documentation.

All documentation received by the Office of Disability Services is considered confidential and will be treated as such.

Listed below is information regarding documentation submitted to SDSU, which is based on suggested practices from AHEAD (Association on Higher Education and Disability).

1. The credentials of the evaluator(s).

     a) Submitted documentation should be produced by a licensed professional who has undergone appropriate and comprehensive training, has relevant experience,  and has no personal relationship with the individual being evaluated, including family members or close family friends.

2. A diagnostic statement identifying the disability.

     a) Submitted documentation should include:

  • A clearly stated diagnosis of disability or disabilities.
  • A clear diagnostic statement that describes how the condition(s) was diagnosed, including, where applicable:
    • A description of the diagnostic criteria
    • Evaluation methods and tests
    • The clinical narrative.
    • Specific results, including where applicable, summary data and specific test results.
  • Diagnostic codes from the Diagnostic Statistical Manual of the American Psychiatric Association (DSM), when appropriate, are strongly encouraged.
  • Provides information on the functional limitations or current impact on the individual.
    • The documentation should be thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition(s)

3. Age of document

     a) Relatively recent documentation, dated within 1-5 years of the request, is acceptable in most circumstances.

     b) Older documentation of conditions that are unchanging in nature, is acceptable.

4. A description of current and past accommodations, services and/or medications.

     a) A description of both current and past accommodations, support services, medications, auxiliary aids and assistive devices, including their effectiveness in ameliorating functional impacts of the disability, is very helpful. A discussion of any significant side effects from current medications or services that may impact physical, perceptual, behavioral or cognitive performance is helpful. Please note that SDSU has no obligation to provide accommodations previously provided by outside entities.

5. Recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or collateral support services.

    a) Recommendations from professionals with a history of working with the individual may provide information useful in the planning process. Please note the SDSU  has no obligation to provide or adopt recommendations made by outside entities

Mental Health Condition Documentation Quick Reference Guide

In order to ensure the provision of reasonable accommodations for students with disabilities, the Office of Disability Services requires documentation from a qualified physician or other licensed professional in a field related to the disability that provides verification of the disability, a description of the current functional limitations noted as a result of the disability on a major life activity (e.g. concentrating, learning) and any recommendations of possible accommodations. 

1. The documentation should include the following information: 

     a) A statement of the mental health condition as a DSM-5 diagnosis. Please include the date of diagnosis and the date of last contact with this student. 

     b) A brief summary of the information gathered from the clinical interview, rating scales, and test instruments used to assess/diagnose the mental health condition and rule out other explanations. 

     c) A description of the current severity of the mental health condition and this student's limitations in an academic setting. 

     d) A list of medication or other treatments the student is currently utilizing, including any possible medication/treatment side effects. 

     e) A description of any accommodations you feel would be appropriate for this student given his/her limitations. A rationale, which is linked to the student's  limitations in an academic setting, should be provided for each accommodation. 

     f) A description of any referrals for further testing/evaluation or treatment. 

     g) Attach any additional information you feel is relevant in determining accommodations for this student. 

2. The prepared documentation should: 

     a) Be on letterhead. 

     b) Be typed, dated, and bear the signature of the provider. 

     c) Include the name, title, and professional credentials of the provider, including information about licensure and certification. 

     d) Include contact information (e.g. name, address, and phone number of the practice). 

Please contact the Office of Disability Services at 605-688-4504 or via email at SDSU.DisabilityServices@sdstate.edu, if you have any questions.