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General Documentation Guidelines

Accurate documentation of your disability is vital in order for our Disability Services to fully evaluate your request for special accommodations, auxiliary aids, or services.  

In order to assist you and your healthcare professional in properly and thoroughly completing your documentation, please follow these general guidelines: 

  1. Include evaluator credentials. The professional who is assessing your condition and helping you complete your documentation must demonstrate appropriate training, licensure, and experience for his/her profession. A match between this professional’s credentials and your condition is expected.
  2. Include a diagnostic statement identifying your disability. Be sure to include a clear diagnostic statement that describes how your condition was diagnosed, the functional impact it has had on you, and its typical progression. When appropriate, include International Classification of Diseases (ICD) or Diagnostic Statistical Manual (DSM) codes, as well as your most recent evaluation. However, if this was not a full evaluation, please indicate the date of your last full evaluation.
  3. Include a description of the diagnostic methodology used. Documentation must include a description of the diagnostic criteria met for your diagnosis, the evaluation methods used, all administered tests and dates, and a clinical narrative. When appropriate to the nature of your disability, we recommend you also include summary data and specific test scores.
  4. Include the current functional impact of your condition. Information on how your disability is currently impacting you is essential in establishing our recommendation for possible accommodations. Documentation should be thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of severity and variability over time and/or environmental conditions. Any relevant functional impact on your physical, perceptual, cognitive, or behavioral ability should be either described as a clinical narrative or supported by specific results from your diagnostic procedures/assessments.
  5. Describe your disability’s expected progression or stability. It is best to provide information on expected changes in the functional impact of your disability over time and context. Information on the cyclical or episodic nature of your disability plus any known or suspected environmental triggers to episodes provides opportunities for our team to anticipate and plan for varying functional impacts. If your condition is not considered stable, it would be extremely helpful if you included information on interventions and recommended timelines for re-evaluation.
  6. Describe both past and current accommodations, services, and/or medications. Please describe all accommodations, services, auxiliary aids, assistive aids, and/or medication you have had in the past. Be sure to include their past effectiveness in minimizing the functional impacts of your disability. Also, please describe any significant side effects from your current medication. Note: Although any accommodations provided to you at another institution do not necessarily guarantee the same at Terra, they will provide us valuable insight in helping to promote your equal access to an education here.
  7. Include recommendations for accommodations, adaptive/assistive devices, auxiliary services, and/or support services. Recommendations from any professionals who have worked with you will provide us valuable information. Of course, recommended accommodations and services should be logically related to your functional limitations. If, however, these connections are not that obvious, a clear explanation of their relationship should be presented. When recommendations go beyond the equitable and inclusive services and benefits that we offer, they may still be useful in suggesting alternative accommodations and services.

Contact us for more information.

If you have any further questions or would like to learn more about our general documentation guidelines, please contact:

Dori Dalton, MSW, LISW-S - Director of Academic Service Center Counseling and Disability Services
Location: B105, General Technologies Building
Email: ddalton01@terra.edu
Phone: 419.559.2342
Toll Free: 866.288.3772