Documentation Guidelines Overview

The intent of UAB DSS is not to exclude students from receiving services, but to ensure that those with qualifying disabilities who have current functional limitations receive appropriate services. Accommodations are determined by student input of his/her (their)history of and experience with disability and accommodations, disability documentation which should corroborate the student’s request for accommodations, and a deliberative and collaborative process with DSS staff that is responsive to the unique experience of each individual.

The rationale for seeking information about a student’s condition is to support the DSS professional in establishing disability, understanding how disability may impact a student and making informed decisions about reasonable accommodations. DSS staff view students’ input/self-report about their disability as a valuable and vital source of information in determining reasonable accommodations. Students should be prepared to discuss their disability, how their disability impacts their academics, and accommodations which have been helpful in the past.

In addition to self-report, documentation provides vital information about the functional limitations of the student’s disability and its impact in a post-secondary academic environment. Documentation is requested in order to establish that a student has a disability*, understand the unique functional impact of the disability, and ascertain how and why a requested accommodation may be reasonable to ensure nondiscrimination and equal access as outlined under Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990 and the ADA Amendments Act of 2008 (ADAAA).

Documentation guidelines available through DSS are intended to provide guidance to the evaluator. Documentation can be submitted by a student or sent directly from a provider’s office. Documentation of disability will be treated in a confidential manner, stored securely, and shared only on a need-to-know basis consistent with state and federal laws and regulations.

If students have difficulty obtaining documentation of their disability, we encourage students to contact DSS for guidance.

Please note: Documentation guidelines vary among institutions and high stakes testing agencies (i.e., ETS, MCAT, LSAT, etc.). There is no guarantee that documentation accepted by UAB DSS will be accepted by other institutions or testing agencies. Documentation costs are the student’s responsibility.

Attention Deficit Hyperactivity Disorder (ADHD)
and Learning Disabilities

Disability Support Services (DSS) at the University of Alabama at Birmingham (UAB) offers programs and related services that provide equal access to the university’s educational opportunities for students with disabilities.

Documentation of disability is necessary to qualify for these services and programs. The purpose of documentation is to assist DSS in determining a student’s disability* information and their eligibility to receive accommodations. The documentation provided should be from a certified or licensed professional trained to diagnose and treat the condition, including a medical doctor or nurse practitioner.

Generally, school plans such as an IEP or 504 Accommodation Plan are insufficient without accompanying information or testing results. Clinical chart notes or printed electronic records from a patient portal are also generally insufficient as standalone documentation.

Please include a typed letter along with signature, on letterhead, addressing the information listed below. Any additional information or documents you think would be relevant in determining the student’s academic accommodations will also be accepted.

All information provided will be kept within the student’s file at DSS, where it will be held securely and confidentially.

All reports should be current and typed on letterhead, dated, and signed.

The following should be included in the report:

1. Student information including name, date of diagnosis, and date of most recent evaluation

2. Evaluator name, title, and credentials

3. Diagnosis

• Clear statement of the student’s current diagnosis(es) and diagnostic code(s) as per the most recent Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD). (Note: Diagnoses alone cannot be used to support disability.)

4. History to Support Diagnosis

• Description of the nature and severity of the disorder, including childhood symptoms/impairments
• Relevant medical, familial, and social histories

5. Evidence of current impairment

• Description of present symptoms that meet the criteria for the diagnosis
• Description of how the disability currently impacts the student in social, academic, or occupational settings
• Description of how the disability will limit the student in the academic environment

6. Assessment Information

• Provide results and interpretation of any relevant assessment/evaluations conducted to reach diagnosis and rule out differential diagnoses
• Description of the methodologies utilized to reach clinical understanding/diagnosis(es) (Examples may include: interviews, assessments, behavioral observations)

7. Treatment and Medication (if applicable)

• Description of any current medication, therapy, or other treatment being implemented (Medication alone cannot be used to support diagnosis/disability.)
• Description of the impact medication may have on student’s ability to perform in an academic environment

Please return the report or address questions regarding documentation to:

Autism Spectrum Disorders (ASD)/Social Communication Disorders

Disability Support Services (DSS) at the University of Alabama at Birmingham (UAB) offers programs and related services that provide equal access to the university’s educational opportunities for students with disabilities.

Documentation of disability is necessary to qualify for these services and programs. The purpose of documentation is to assist DSS in determining a student’s disability* information and their eligibility to receive accommodations. The documentation provided should be from a certified or licensed professional trained to diagnose and treat the condition, including a medical doctor or nurse practitioner.

Generally, school plans such as an IEP or 504 Accommodation Plan are insufficient without accompanying information or testing results. Clinical chart notes or printed electronic records from a patient portal are also generally insufficient as standalone documentation.

Please include a typed letter along with signature, on letterhead, addressing the information listed below. Any additional information or documents you think would be relevant in determining the student’s academic accommodations will also be accepted.

All information provided will be kept within the student’s file at DSS, where it will be held securely and confidentially.

All reports should be current and typed on letterhead, dated, and signed.

The following should be included in the report:

1. Student information including name, date of diagnosis, and date of most recent evaluation

2. Evaluator name, title, and credentials

3. Diagnosis

• Clear statement of the student’s current diagnosis(es) and diagnostic code(s) as per the most recent Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD). (Note: Diagnoses alone cannot be used to support disability.)

4. History to Support Diagnosis

• Description of the nature and severity of the disorder
• Relevant medical, familial, and social histories

5. Evidence of current impairment

• Description of present symptoms that meet the criteria for the diagnosis
• Description of how the disability currently impacts the student in social, academic, or occupational settings
• Description of how the disability will limit the student in the academic environment

6. Assessment Information

• Provide results and interpretation of any relevant assessment/evaluations conducted to reach diagnosis.
• Description of the methodologies utilized to reach clinical understanding/diagnosis(es) (Examples may include: interviews, assessments, behavioral observations)

7. Treatment and Medication

• Description of any current medication, therapy, or other treatment being implemented (Medication alone cannot be used to support diagnosis/disability.)
• Description of the impact medication may have on student’s ability to perform in an academic environment

Please return the report or address questions regarding documentation to:

Medical

Disability Support Services (DSS) at the University of Alabama at Birmingham (UAB) offers programs and related services that provide equal access to the university’s educational opportunities for students with disabilities.

Documentation of disability is necessary to qualify for these services and programs. The purpose of documentation is to assist DSS in determining a student’s disability* information and their eligibility to receive accommodations. The documentation provided should be from a certified or licensed professional trained to diagnose and treat the condition, including a medical doctor or nurse practitioner.

Generally, school plans such as an IEP or 504 Accommodation Plan are insufficient without accompanying information or testing results. Clinical chart notes or printed electronic records from a patient portal are also generally insufficient as standalone documentation.

Please include a typed letter along with signature, on letterhead, addressing the information listed below. Any additional information or documents you think would be relevant in determining the student’s academic accommodations will also be accepted.

All information provided will be kept within the student’s file at DSS, where it will be held securely and confidentially.

All reports should be current and typed on letterhead, dated, and signed.

Examples of common diagnoses that fall under this category include, but are not limited to: Migraines, Sleep Disorders, Diabetes, Autoimmune Diseases, Epilepsy, Irritable Bowel Syndrome, Chronic Pain, etc.

The following should be included in the report:

1. Student information including name, date of most recent evaluation

2. Evaluator name, title, and credentials

3. Diagnosis

• Clear statement of the student’s current diagnosis(es) and diagnostic code(s) as per the most recent Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) (Note: Diagnoses alone cannot be used to support disability.)

4. History to Support Diagnosis

• Description of the nature, duration and severity of the disorder
• Last contact with individual, date of onset, and symptoms

5. Evidence of current impairment

• Description of present symptoms that meet the criteria for the diagnosis
• Description of how the disability currently impacts the student in social, academic, or occupational settings
• Description of how the disability will limit the student in the academic environment
• Include prognosis of condition
• Describe how the symptoms impact the student’s academics

6. Assessment Information

• Provide results and interpretation of any relevant assessment/evaluations conducted to reach diagnosis.
• Description of the impact on major life activities affected by this disorder such as learning, seeing, hearing, sleeping, walking, reading, concentrating, thinking, etc.

7. Treatment and Medication

• Description of any current medication, therapy, or other treatment being implemented (Medication alone cannot be used to support diagnosis/disability.)
• Address aspects of the student’s treatment plan that should be considered when determining academic accommodations.

Please return the report or address questions regarding documentation to:

Mobility

Disability Support Services (DSS) at the University of Alabama at Birmingham (UAB) offers programs and related services that provide equal access to the university’s educational opportunities for students with disabilities.

Documentation of disability is necessary to qualify for these services and programs. The purpose of documentation is to assist DSS in determining a student’s disability* information and their eligibility to receive accommodations. The documentation provided should be from a certified or licensed professional trained to diagnose and treat the condition, including a medical doctor or nurse practitioner.

Generally, school plans such as an IEP or 504 Accommodation Plan are insufficient without accompanying information or testing results. Clinical chart notes or printed electronic records from a patient portal are also generally insufficient as standalone documentation.

Please include a typed letter along with signature, on letterhead, addressing the information listed below. Any additional information or documents you think would be relevant in determining the student’s academic accommodations will also be accepted.

All information provided will be kept within the student’s file at DSS, where it will be held securely and confidentially.

Examples of common diagnoses that fall under this category include, but are not limited to: Cerebral Palsy, Multiple Sclerosis, Amputation, Spinal Cord Injury, Arthritis, Other conditions impacting mobility

All reports should be current and typed on letterhead, dated, and signed.

The following should be included in the report:

1. Student information including name, date of most recent evaluation

2. Evaluator name, title, and credentials

3. Diagnosis

• Clear statement of the student’s current diagnosis(es) and diagnostic code(s) as per the most recent Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) Note: (Diagnoses alone cannot be used to support disability.)

4. History to Support Diagnosis

• Description of the nature, duration and severity of the disorder
• Last contact with individual, date of onset, and symptoms

5. Evidence of current impairment

• Description of present symptoms that meet the criteria for the diagnosis
• Description of how the disability currently impacts the student in social, academic, or occupational settings
• Description of how the disability will limit the student in the academic environment
• Include prognosis of condition with or without treatment

6. Assessment Information

• Provide results and interpretation of any relevant assessment/evaluations conducted to reach diagnosis.
• Description of the impact on major life activities affected by this disorder such as learning, seeing, hearing, sleeping, walking, reading, concentrating, thinking, etc.

7. Treatment and Medication

• Description of any current medication, therapy, or other treatment being implemented (Medication alone cannot be used to support diagnosis.)
• Address aspects of the student’s treatment plan that should be considered when determining academic accommodations.

Please return the report or address questions regarding documentation to:

Psychological

Disability Support Services (DSS)at the University of Alabama at Birmingham (UAB) offers programs and related services that provide equal access to the university’s educational opportunities for students with disabilities.

Documentation of disability is necessary to qualify for these services and programs. The purpose of documentation is to assist DSS in determining a student’s disability* information and their eligibility to receive accommodations. The documentation provided should be from a certified or licensed professional trained to diagnose and treat the condition, including a medical doctor or nurse practitioner.

Generally, school plans such as an IEP or 504 Accommodation Plan are insufficient without accompanying information or testing results. Clinical chart notes or printed electronic records from a patient portal are also generally insufficient as standalone documentation.

Please include a typed letter along with signature, on letterhead, addressing the information listed below. Any additional information or documents you think would be relevant in determining the student’s academic accommodations will also be accepted.

All information provided will be kept within the student’s file at DSS, where it will be held securely and confidentially.

Examples of common diagnoses that fall under this category include, but are not limited to: Major Depressive Disorder, Anxiety Disorders (including Generalized Anxiety Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder), Bipolar Disorder, Personality Disorders, Schizophrenia Spectrum Disorders, Dissociative Disorders, Eating Disorders, and Tourette’s Disorder.

All reports should be current and typed on letterhead, dated, and signed.

The following should be included in the report:

1. Student information including name, date of diagnosis, and date of most recent evaluation

• Accommodations are based on assessment of the current nature and impact of disability. Because psychological conditions may change over time, current evaluations can be critical for providing reasonable accommodations. Depending on the nature of the disability, updated evaluations may be requested.

2. Evaluator name, title, and credentials

3. Diagnosis

• Clear statement of the student’s current diagnosis(es) and diagnostic code(s) as per the most recent Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD). (Note: Diagnoses alone cannot be used to support disability.)

4. History to Support Diagnosis

• Description of the nature, duration, frequency, and severity of the disorder
• Relevant medical, familial and social histories

5. Evidence of current impairment

• Description of present symptoms that meet the criteria for the diagnosis
• Description of how the disability currently impacts the student in social, academic, or occupational settings
• Description of how the disability will limit the student in the academic environment
• Include prognosis of condition with or without treatment

6. Assessment Information

• Provide results and interpretation of any relevant assessment/evaluations conducted to reach diagnosis.
• Description of the methodologies utilized to reach clinical understanding/diagnosis(es) (Examples may include: interviews, assessments, behavioral observations)

7. Treatment and Medication

• Description of any current medication, therapy, or other treatment being implemented (Medication alone cannot be used to support diagnosis/disability.)
• Description of the impact medication may have on student’s ability to perform in an academic environment

Please return the report or address questions regarding documentation to:

Sensory

Disability Support Services (DSS) at the University of Alabama at Birmingham (UAB) offers programs and related services that provide equal access to the university’s educational opportunities for students with disabilities.

Documentation of disability is necessary to qualify for these services and programs. The purpose of documentation is to assist DSS in determining a student’s disability* information and their eligibility to receive accommodations. The documentation provided should be from a certified or licensed professional trained to diagnose and treat the condition, including a medical doctor or nurse practitioner.

Generally, school plans such as an IEP or 504 Accommodation Plan are insufficient without accompanying information or testing results. Clinical chart notes or printed electronic records from a patient portal are also generally insufficient as standalone documentation.

Please include a typed letter along with signature, on letterhead, addressing the information listed below. Any additional information or documents you think would be relevant in determining the student’s academic accommodations will also be accepted.

All information provided will be kept within the student’s file at DSS, where it will be held securely and confidentially.

Examples of common diagnoses that fall under this category include, but are not limited to: Blindness or low vision, Deafness or hearing loss

All reports should be current and typed on letterhead, dated, and signed.

The following should be included in the report:

1. Student information including name, date of most recent evaluation

2. Evaluator name, title, and credentials

3. Diagnosis

• Clear statement of the student’s current diagnosis(es) and diagnostic code(s) as per the most recent Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD). (Note: Diagnoses alone cannot be used to support disability.)

4. History to Support Diagnosis

• Description of the nature, duration (stable, progressive, temporary), nature and severity (i.e. mild, moderate, or severe)
• Last contact with individual, date of onset, and symptoms

5. Evidence of current impairment

• Description of how the disability currently impacts the student in social, academic, or occupational settings
• Description of how the disability will limit the student in the academic environment

6. Assessment Information

• Provide results and interpretation of any relevant assessment/evaluations conducted to reach diagnosis.
  • Vision (examples include ocular assessment, low-vision evaluation or visual acuity assessment)
  • Hearing (examples include audiological evaluation or audiogram)
• Description and interpretation of results of the above assessments. Based on results, how will student be functionally limited in an academic setting?

7. Treatment and Medication

• Address aspects of student’s treatment plan that should be considered when determining academic accommodations.
• Describe any auxiliary aids (assistive listening devices, communication access accommodation), assistive technologies, visual aids) that should be considered.

Please return the report or address questions regarding documentation to:

Traumatic Brain Injury (TBI)

Disability Support Services (DSS) at the University of Alabama at Birmingham (UAB) offers programs and related services that provide equal access to the university’s educational opportunities for students with disabilities.

Documentation of disability is necessary to qualify for these services and programs. The purpose of documentation is to assist DSS in determining a student’s disability* information and their eligibility to receive accommodations. The documentation provided should be from a certified or licensed professional trained to diagnose and treat the condition, including a medical doctor or nurse practitioner.

Generally, school plans such as an IEP or 504 Accommodation Plan are insufficient without accompanying information or testing results. Clinical chart notes or printed electronic records from a patient portal are also generally insufficient as standalone documentation.

Please include a typed letter along with signature, on letterhead, addressing the information listed below. Any additional information or documents you think would be relevant in determining the student’s academic accommodations will also be accepted.

All information provided will be kept within the student’s file at DSS, where it will be held securely and confidentially.

All reports should be current and typed on letterhead, dated, and signed.

The following should be included in the report:

1. Student information including name, date of diagnosis, date of most recent evaluation

2. Evaluator name, title, and credentials

3. Diagnosis

• Clear statement of the student’s current diagnosis(es) and diagnostic code(s) as per the most recent Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) Note: (Diagnoses alone cannot be used to support disability.)

4. History to Support Diagnosis

• Description of the nature and severity of the injury
• Last contact with individual, date of onset, and symptoms

5. Evidence of current impairment

• Description of how the injury currently impacts the student in social, academic, or occupational settings
• Description of how the injury will limit the student in the academic environment

6. Assessment Information

• Results and interpretation of assessment addressing student’s cognitive abilities, including processing speed and memory (post-rehabilitation and within one year)
• Results and interpretation of any achievement testing conducted including scores and subscores

7. Treatment and Medication

• Description of any current medication, therapy, or other treatment being implemented
• Description of the impact medication may have on student’s ability to perform in an academic environment

Please return the report or address questions regarding documentation to:

Assistance Animal Guidelines

All reports should be current and typed on letterhead, dated, and signed.

An assistance animal , also referred to as emotional support animals, are animals that have been prescribed by a medical or psychiatric health provider as playing a role in the treatment of a disability. Assistance animals are not pets, but rather a part of an ongoing therapeutic relationship that is integrated into treatment.

UAB works with students to make reasonable accommodations for assistance animals in accordance with federal guidance. These guidelines are intended to help you and your provider in preparation of documentation. Please keep in mind that thoroughly addressing guidelines helps Disability Support Services in determinations of disability and disability need for assistance animals.

The following should be included in the report:

1.Student information including name, date of most recent evaluation

• Name, qualifications, licensure, office information
• Length of time the provider and student have been in a therapeutic relationship
• Nature of practice with student (monthly medication management, psychotherapy, case management, etc.)

3. History to support diagnosis:

• Description of the duration and severity of the disorder
• Relevant medical, familial, and social histories
• Length of time animal has been prescribed in care
• Evidence of reduced symptomology, improved functioning from assistance animal treatment role

4. Evidence of current impairment:

• Description of how disability currently impacts the student in social, academic, or occupational settings
• Description of how the disability will limit the student in a residential setting
• Discussion of how the assistance animal is necessary for the resident to use
• and enjoy College housing as compared to a person without a disability

5. Assessment information:

• Results and interpretation of specific evaluation data to support diagnosis

6. Treatment and medication:

• Description of any current medication, therapy, or other treatment being implemented
• Identification of the animal (name, species)
• Identification of the animal’s role in the treatment plan
• Description of the medically necessary assistance the animal provides to the
• student

7. Diagnosis:

• Clear statement of diagnosis including the DSM-5 or ICD-10 diagnostic code

8. Recommended accommodations:

• Include specific recommendations for academic accommodations and the rationale for the accommodations

Download the Assistance Animal Guidelines.

ASSISTANCE ANIMAL GUIDELINES

Please return the report or address questions regarding documentation to: