Documentation Guidelines for Learning Disabilities
1. Be completed by a qualified evaluator: Professionals conducting assessments, rendering diagnoses of LD, offering clinical judgments, and making recommendations for accommodations must be qualified to do so. See section I of the policy statement.
2. Include test taker’s identifying information: In addition to the test taker’s identifying information, the name, title, and professional credentials of the evaluator should be included on letterhead, typed in English, dated, and signed. See section I of the policy statement.
3. Be current: In most cases, a diagnostic evaluation must have been completed within the past five years.
4. Include a comprehensive history: Include a comprehensive history of presenting problems associated with the disability as well as information on the test taker’s medical, developmental, educational, and family history. This should also include the date of diagnosis, duration, and severity of the disorder.
5. Include relevant observations of behavior during testing: Include observations of behavior during the diagnostic evaluation which may help to form a diagnostic impression when combined with the clinician’s professional judgment and expertise.
6. Include a comprehensive battery of cognitive and achievement tests, using the most recent edition of measure, with adult norms: In most cases, a psychoeducational or neuropsychological assessment will be useful in determining the degree to which the learning disability currently impacts the individual relative to taking standardized tests. See section VI, B of the policy statement. See section (Appendix B) for a full list of tests for assessing adolescents and adults with learning disabilities.
7. Include all test scores using standardized adult measures: See section VI, D of the policy statement.
8. Provide specific diagnosis/diagnoses: Include at least one specific diagnosis based on the latest edition of the DSM or the ICD and indicate the level of severity of the disability.
9. Discuss the current impact of the disorder on academic performance, employment, and other daily activities: Include additional sources of information such as school-based records (e.g., IEP, Section 504 Plan) or other related documents regarding the test taker’s history, eligibility for services, and/or history of accommodations use in school and/or employment. See section V of the policy statement.
10. Include specific recommendations with a rationale based on objective evidence: Establish a link between the requested accommodations and the manifested symptoms of the learning disability that is pertinent to a standardized testing situation.
11. Include an interpretative summary: The interpretative summary at the end of the report should rule out, to the extent possible, other potential diagnoses that may alter the expression of the disability, including cross-cultural factors, ESL, lack of educational opportunity, and/or medical conditions that may mimic a disability. A documentation update is required for diagnostic evaluations not completed within the last five years. A documentation update is a brief report or narrative by a qualified professional that includes a summary of the previous disability documentation findings as well as additional clinical and observational data to establish the test taker’s current need for accommodations. This provision is only applicable to test takers with LD, ADHD, and/or LD/ADHD.