Documentation Guidelines

Monroe Community College has established guidelines for documenting disability information that qualify an individual for services.  These guidelines are intended to provide comprehensive and relevant information regarding the current functional limitations caused by the disability and/or medical condition. All disability-related information received by the College is treated as strictly confidential.

Documentation must be written by a licensed or credentialed examiner. Appropriate documentation may include a relevant psychological evaluation; medical letter/report from a qualified evaluator. Along with a comprehensive evaluation, other helpful documents include an Individual Education Plan (IEP), 504 Plan, Audiogram, etc.

Example of documentation on letterhead by a qualified evaluator:  

1. A diagnostic statement identifying the condition(s).
   Include the date of the most recent evaluation performed by referring professional(s) and as appropriate, include ICD or DSM codes.
2. Current functional impact of the condition(s).
   The current functional impact on physical (including mobility dexterity, and endurance), perceptual, cognitive (including attention, distractibility, and communication), and behavioral concerns should be described as clinical narrative and/or through the provision of specific results from the diagnostic procedures. Descriptions should provide a sense of severity, information on variability over time or circumstance, and potential environmental triggers.
3. Treatments, medications, assistive devices/services currently prescribed or in use. 
   A description of treatments, medications, assistive devices, accommodations and/or assistive services currently used and their estimated effectiveness in improving the impact of the condition(s). Please include any significant side effects that may impact physical, perceptual, behavioral or cognitive performance.
4. The expected progression or stability of the impacts described over time.
   Provide a description of the change in the functional impacts of the condition(s) over time and/or recommendations concerning the predictable needs for reevaluation. If the condition is variable (based on known cycles or environmental triggers) are they under self-care for flare-ups or episodes.
5. Recommended accommodations and services.
   Recommendations should be based on current functional limitations of the condition.
6. Supporting Documentation.
   Along with this comprehensive report, other helpful documents may include: psycho-educational evaluation, Individualized Education Plan (IEP), 504 Plan, and/or teacher reports.

Any additional costs associated with assessments/evaluations are the responsibility of the student.