The College of New Jersey

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Documentation

Guidelines

  • For ADD/ HD
  • For Psychiatric Disabilities
  • For Cognitive Disabilities
  • For Physical, Medical, and Sensory Disabilities
  • For Learning Disabilities

All documentation must be on a professional letter head. Any documentation on prescription pads will not be accepted. All documentation can be faxed or mailed, but a hard copy for the file is required.Colleges are not required to provide evaluations for students with disabilities.Colleges are required to provide reasonable accommodations once a student provides appropriate disability documentation.

For ADD/ HD:

  1. Documentation must include a medical or clinical diagnosis of ADD/HD based on DSM-IV criteria and a rationale for the diagnosis.
  2. The evaluation must be performed by an appropriate professional, a medical doctor or a clinical psychologist, who is knowledgeable regarding ADD/HD.  The evaluator’s name, title, and professional credentials and affiliation should be provided.
  3. The documentation should include the following:
    • Quantitative and qualitative information that supports the diagnosis;
    • Summary and interpretation of assessment instruments (formal assessment instruments and/or clinical interview);
    • Information regarding the specific academic functions affected by and the severity of the disability (e.g., ability to sustain attention, distraction index);
    • Recommendations for and compliance to prescriptive treatment, including medication;
    • Recommendations for academic accommodations based on specific features/symptoms of disability;
    • Investigation/evaluation of dual and/or confounding diagnosis (e.g., mood, behavioral, neurological, learning, personality disorders).
  4. Documentation must reflect the current (within the past year) array of symptoms/features and level of functioning; if the documentation does not, students may be required to submit up-dated information and/or documentation. Documentation should be from as close to senior year as possible.
  5. Neither a 504 plan nor an individualized educational plan (IEP) constitute sufficient documentation but may be submitted along with a medical or clinical evaluation.

If you need to get an updated evaluation, here are some guidelines to follow.


For Psychiatric Disabilities:

  1. Documentation must include a medical or clinical diagnosis of a psychiatric disability based on DSM-IV criteria and a rationale for the diagnosis.
  2. The evaluation must be performed by an appropriate professional: a psychiatrist, a clinical psychologist, a licensed professional counselor, or a clinical social worker.  The evaluator’s name, title, and professional credentials and affiliation should be provided.
  3. The documentation should include the following:
    • Information regarding the severity of the disability and the specific academic functions affected by the disability and/or medication (e.g., ability to concentrate, ability to attend class regularly, ability to interact in small/large groups);
    • Recommendations for and compliance to prescriptive treatment, including medication;
    • Recommendations for academic accommodations based on specific features/symptoms of disability.
  4. Documentation must reflect the current array of symptoms/features and level of functioning; if the documentation does not, students may be required to submit up-dated information and/or documentation.

For Cognitive Disabilities:

  1. A psycho-educational evaluation that provides a diagnosis of a cognitive disability must be submitted. A statement indicating the current status and impact of the disability in an academic setting should be included. If another diagnosis is applicable (e.g., ADD/HD), mood disorder), it should be stated.
  2. The evaluation must be performed by a certified/licensed professional. The evaluator’s name, title, and professional credentials and affiliation should be provided.
  3. The evaluation should be based on a comprehensive assessment battery:
    • Aptitude: Average broad cognitive functioning must be demonstrated on an individually administered intelligence test, such as the WAIS-R, WAIS-III, WISC-R, WISC-III, or WJ-R Cognitive Battery. Subscales/subtests scores should be listed.
    • Academic Achievement: A comprehensive academic achievement battery, such as WJ-R, must document achievement deficits relative to potential. The battery should include current levels of academic functioning in relevant areas, such as reading (comprehension, decoding), oral and written language, and mathematics. Standard scores, grade levels, and percentages for subtests administered should be stated.
    • Information Processing: Specific areas of information processing (e.g., short- and long-term memory, abstract reasoning) should be assessed.
    • Social-Emotional Assessment: To provide information needed to establish appropriate services, a social-emotional assessment, using formal assessment instruments and/or clinical interview, should be conducted.
    • Clinical Summary: A diagnostic summary should present a diagnosis of a cognitive disability; provide impressions of the testing situation; interpret the testing data; indicate how patterns in cognitive ability, achievement, and information processing reflect the disability; and recommend specific accommodations based on disability-related deficits.
  4. For students just graduating high school, an evaluation reflecting current levels of academic skill should have been administered during their high school tenure; for students who have been out of school for a number of years, documentation will be considered on a case by case basis.  Students may be required to submit up-dated information and/or documentation. Documentation should be from as close to senior year as possible.
  5. Additional documents that do not constitute sufficient documentation, but that may be submitted in addition to a psychological or psycho-educational evaluation are: an individualized educational plan (IEP), a 504 plan, and/or an educational assessment.

For Physical, Medical, and Sensory Disabilities:

  1. Documentation must include a medical diagnosis.
  2. The diagnosis and evaluation should be made by a medical doctor or appropriate specialist licensed in the specific field of disability. The evaluator’s name, title, and professional credentials and affiliations should be provided.
  3. The documentation should include the following:
    • The stability of the disability (Is the disability stable, progressive, fluctuating?);
    • Information regarding the specific academic functions affected by and the severity of the disability (e.g., ability to concentrate, ability to attend class regularly);
    • Recommendations for academic accommodations based on specific features/symptoms of the disability (e.g., adaptive technology/equipment).
  4. The recency of the documentation is dependent on the nature/stability of the disability.
  5. Documentation must reflect the current array of symptoms/features and level of functioning; if the documentation does not, students may be required to submit up-dated information and/or documentatin. Documentation should be from as close to senior year as possible.

For Learning Disabilities:

  1. A psycho-educational or neuropsychological evaluation that provides a diagnosis of a specific learning disability must be submitted.  A statement indicating the current (eleventh/twelfth grade) status and impact of the learning disability in an academic setting should be included.  If another diagnosis is applicable (e.g., ADD/HD, mood disorder), it should be stated.
  2. The evaluation must be performed by a professional who is certified/licensed in the area of learning disabilities.  The evaluator’s name, title, and professional credentials and affiliation should be provided.
  3. The evaluation should be based on a comprehensive assessment battery:
    • Aptitude: Average broad cognitive functioning must be demonstrated on an individually administered intelligence test, administered during high school tenure, such as the WAIS-R, WAIS-III, WISC-R, WISC-III, or WJ-R Cognitive Battery.  Subscales/subtests scores should be listed.
    • Academic Achievement: A comprehensive academic achievement battery, such as WJ-R, must document achievement deficits relative to potential.  The battery should include current levels of academic functioning in relevant areas, such as reading (comprehension, decoding), oral and written language, and mathematics.  Standard scores, grade levels, and percentages for subtests administered should be stated.
    • Information Processing: Specific areas of information processing (e.g., short- and long term memory, auditory, and visual perception/processing, executive functioning) should be assessed.
    • Social-Emotional Assessment: To rule-out a primary emotional basis for learning difficulties and provide information needed to establish appropriate services, a social-emotional assessment, using formal assessment instruments and/or clinical interview, should be conducted.
    • Clinical Summary: A diagnostic summary should present a diagnosis of a specific learning disability; provide impressions of the testing situation; interpret the testing data; indicate how patterns in cognitive ability, achievement, and information processing reflect the specific learning disability; recommend specific accommodations based on disability-related deficits; and rule out alternative explanations for and include factors contributing to academic difficulties.
  4. For students just graduating high school, an evaluation reflecting current levels of academic skills should have been administered while in high school; for students who have been out of school for a number of years, documentation will be considered on a case by case basis. Students may be required to submit up-dated information and/or documentation. Documentation should be from as close to senior year as possible.
  5. Additional documents that do not constitute sufficient documentation, but that may be submitted in addition to a psychological, psycho-educational, or neuropsychological evaluation are: an individualized educational plan (IEP), a 504 plan, and/or an educational assessment.

If you need to get an updated evaluation, here are some guidelines to follow.

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