Documentation Guidelines:
This guideline provides an overview of disability documentation requirements. While SAS allows for some flexibility in the documentation, it takes pride in maintaining a transparent and clear process for evaluating disability accommodation requests. Additionally, SAS reserves the right to verify all submitted documentation.
- Qualifications of Clinician/Provider: Documentation: Must be typed on letterhead, dated, and signed by a licensed or certified professional. Include name, title, and credentials. Family members cannot provide documentation.
- Diagnosis and History: Provide a diagnostic statement identifying the disability with ICD or DSM classification, along with relevant personal, psycho-social, medical, developmental, and educational history.
- Description of Diagnostic Methodology: Include details of the diagnostic methods used, data from evaluation instruments, and results that link to the diagnosis and functional limitations. Use adult norms for cognitive disorders.
- Current Impact and Functional Limitations: Describe the severity, current impact, and functional limitations in academic and/or residential settings, noting if symptoms are constant or episodic, and their frequency or duration.
- Current Treatments: List any prescribed treatments, medications, and assistive devices/services, including their effects and potential side effects.
- Recommendations: Provide recommendations with rationale linked to the impact and functional limitations.
Documentation Request Form – to be completed by the student’s treating professional or provider:
In an effort to streamline the information-sharing process, SAS has developed this form to assist providers in sharing relevant details about the patient/client. While completing the form is not required, it is a helpful tool that ensures we receive the information needed to evaluate the student’s request and determine appropriate disability-related support. We encourage clear and detailed responses that address the student’s diagnosed condition. If you prefer not to use this form, equivalent documentation covering similar information is welcome.
Documentation Request Form
Note: SAS will make the final determination on eligibility and necessary academic adjustments.
Emotional Support Animal (ESA) Documentation:
SAS provides a non-mandatory form for ESA requests. Regularly, mental health providers suggest an ESA as part of a treatment plan. However, SAS will not accept letters from providers who have seen the student only once for the purpose of obtaining an ESA letter.
Be aware that some websites sell ESA letters and certifications without proper evaluation, which are generally insufficient to establish a legitimate need for an assistance animal. Documentation must:
- Reflect an ongoing diagnostic and therapeutic relationship.
- Confirm that the ESA is necessary for the student to reside on campus.
- Clearly describe how the animal will mitigate functional limitations.
Insufficient Documentation:
SAS does not diagnose impairments or assess their severity or impact. Therefore, office medical records, medical chart notes, or prescription pad notations are generally inadequate for determining eligibility and may prolong the decision process.
Documentation based solely on self-report questionnaires is not considered clinically valid. While clinicians may use them to identify areas for further exploration, they are not diagnostic tools and do not provide a sufficient basis for recommending treatments or accommodations.
IEP or 504 plans that do not clearly list a diagnosis may not be accepted as disability documentation.
Documentation guidelines vary by institution. SAS guidelines are tailored to meet the needs of North Carolina Central University. If a student plans to attend a different institution or take a standardized test administered by an outside agency, they are responsible for researching those documentation policies.
