Documentation Guidelines

The guidelines for documentation below are utilized to enhance consistency and provide students and professionals with the information needed to assist students in establishing eligibility for services and receiving appropriate reasonable accommodations.  The guidelines are broad enough to allow for flexibility in accepting documentation from a range of perspectives given the different educational environments within the University of Maryland’s Schools on the Founding campus. 

1. The credentials of the evaluator.

The University of Maryland does not test for or diagnose learning or other disabilities for the purpose of classroom or exam accommodations.  Documentation must be completed by an external licensed or otherwise properly credentialed professional who has appropriate training and experience, and has no close, personal relationship with the student being evaluated.  A good match between the credentials of the individual making the diagnosis and the disability being reported is expected (e.g., an orthopedic limitation might be documented by a physician but not by a licensed psychologist).  All reports should be typed, dated, presented on the evaluator’s letterhead, and signed.  

2. A diagnostic statement identifying the disability.

Documentation must include a clear diagnostic statement identifying the disability and the date of the most current diagnostic evaluation, as well as the date of the original diagnosis, as appropriate.  While diagnostic codes from the Diagnostic Statistical Manual of the American Psychiatric Association (DSM) or the International Classification of Functioning Disability and Health (ICF) of the World Health Organization are helpful in providing this information, a full clinical description can also convey the necessary information.

3. A description of the diagnostic methodology used.

Documentation must include a description of the current diagnostic criteria, evaluation methods, procedures, tests and dates of administration, as well as a clinical narrative interpretation.  Where appropriate to the nature of the disability (e.g., learning and cognitive disorders) the report should contain both summary data and specific tests scores.

Diagnostic methods that are congruent with the particular disability and current professional practices in the field are expected.  Methods may include formal instruments, medical examinations, structured interview protocols, performance observations and unstructured interviews.  If results from informal or non-standardized methods of evaluation are reported, a clear explanation of their role and significance in the diagnostic process should be included.

4. A description of the current functional limitations.

Documentation must include information on how the disability currently impacts the individual.  A combination of the results of formal evaluation procedures, clinical narrative, and the individual’s self report is the most comprehensive approach to fully documenting impact.  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 disability. While relatively recent documentation is recommended in most circumstances, older documentation of permanent or non-varying disabilities will be accepted.  Likewise, changes in the disability and/or changes in how the disability impacts the individual as a result of growth and development may warrant more frequent updates in order to provide an accurate picture.  Additionally, if changes in accommodations are needed, updated documentation may be required.  In other words, the recency of the documentation depends on the facts and circumstances of the student’s disability and the accommodations requested.

UM’s Office of Educational Support and Disabilities Services, based on their staff members’ professional judgment, may consider accepting older documentation.  Students may receive provisional accommodations on a case by case basis, while obtaining necessary documentation to qualify the disability.

5. A description of the expected progression or stability of the disability.

Documentation must provide information on expected changes in the functional impact of the disability over time and context, if the disability is cyclical or episodic in nature (e.g., bipolar disorder, some chronic medical conditions).  Information regarding known or suspected environmental triggers to episodes can be helpful in anticipating and planning for varying functional impacts.  If the disability is not stable, information on interventions (including the individual’s own strategies) for exacerbations and recommended timelines for reevaluation are most helpful.

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

Documentation should include a description of both current and past accommodations, services, medications, auxiliary aids and assistive devices, including their effectiveness in ameliorating functional impacts of the disability.  A discussion of any significant side effects from current medications or services that may impact physical, perceptual, behavioral or cognitive performance can be helpful.  While accommodations provided in another setting are not binding on the current institution, they may provide insight in making current decisions.

7. Recommendations for reasonable accommodations and services.

Documentation should include recommendations for accommodations and services.  Recommendations from professionals with a history of working with the student can provide valuable information for review and planning.  The recommended accommodations and services should be logically related to the student’s functional limitations. 

While the University of Maryland has no obligation to provide or adopt recommendations made by outside entities, those that are congruent with the institution’s courses, programs and services may be appropriate.  The University of Maryland may substitute another accommodation, if it is considered to be effective and parallel to the one recommended and/or requested.  When recommendations go beyond equitable and inclusive services and benefits, they may still be useful in suggesting alternative accommodations and services.