General Documentation Guidelines
- Specific, detailed diagnosis for each physical or mental impairment, substantiated by DSM-V (for psychological) or ICD-10 (for medical) designation.
- Statement as to whether each physical or mental impairment is permanent or temporary; if temporary, the expected duration of the impairment.
- Information as to how each physical or mental impairment directly and currently affects the individual with regard to physical, emotional, cognitive or other limitations, to what level of severity the physical or mental impairment impacts the individual’s major life activities (for example, walking, hearing, seeing, learning, communicating, breathing, and so forth).
- What impact does the physical or mental impairment have in the context of the classroom/learning environment?
- How are the impairments mitigated, corrected, or managed by assistive devices (such as hearing aid, walker) medications, treatments or other coping mechanisms?
- If student is taking medication for treatment of conditions, note any possible or existing side effects and how these can affect the client in daily functioning and within the classroom environment.
- Specific recommendations as to what reasonable accommodations (such as note taker, extended testing time, sign language interpreter, etc.) are necessary for equal access in the academic environment. (Note: This does not ensure this specific accommodation will be provided.)
Only upon receipt of documentation will the student be considered for reasonable accommodation. Documentation will be viewed in both a historical and current context, but providing documentation does not automatically qualify a student for accommodations through CAP. For example, some educational diagnostic reports (such as Admission Review Dismissal, or A.R.D., reports and 504 Plans) and medical reports (physician’s release to return to work) may not be considered independently sufficient in determining accommodation, but will be considered with other supporting documents.
Once CAP receives the documentation, it becomes part of the student’s educational record and is protected under the Family Educational Rights and Privacy Act.
Any questions from the physician/diagnostician may be directed to the Assistant Director, Disability Accommodations, CAP Office at 817-735-2134, fax 817-735-0263.
This page was last modified on March 23, 2018