Opening / Closing Files
A file will be opened for any student who contacts Disability Services and expresses a desire to receive accommodations, receives a clinical referral, or submits documentation of disability. Files will remain open as long as the student maintains contact with Disability Services. A staff member will attempt to reach by phone, email, or letter, any student with an open file who does not have contact with Disability Services for more than one semester. Student files may be closed if the student does not respond to staff attempts at contacting him or her. Files may also be closed at any time at the request of the student. Closed files will be maintained for a minimum of seven years and will then be destroyed by shredding.
In order to qualify for services and accommodations on the basis of disability, students must submit a Request for Disability Services Accommodation Form (click the link, or see page 29 of Student Disability Services Handbook for the form) in addition to the appropriate clinical documentation directly to Disability Services. All documentation is to be submitted in hard copy form to the Coordinator of Disability Services. This documentation should meet the established documentation guidelines. The following guidelines are intended to assist clinicians in their preparation of reports and to inform clients as consumers of clinical services. Additionally, the following guidelines are not intended to comprehensively address the unique information needed for different types of disabilities. Further, some accommodation requests (e.g., single room placement) will require additional substantiation of need. Thus, Disability Services reserves the right to require the provision of specific information on a case by case basis.
General Documentation Guidelines
- The documentation must be based upon an evaluation by a healthcare or mental health professional appropriately licensed by the state to diagnose medical, psychological, and learning disorders. Such persons are usually physicians, psychiatrists, psychologists, and school psychologists. Documentation from third parties or from persons not licensed to diagnose such conditions will not be accepted.
- Documentation will be accepted from student interns and from clinicians under supervision provided the supervisor is qualified and appropriately licensed. The supervisor must co-sign the report and must list his/her license number.
- The clinician submitting the documentation must not be a family member or relative of the student.
- The documentation must be based upon a clinical evaluation thorough enough to objectively establish the need for accommodations and/or services.
- The documentation should be printed on professional letterhead and signed by the evaluator. Additionally, the license number of the clinician is requested.
- The documentation should include the contact information for the clinician.
- Disability Services asks that a copy of the person’s signed release of information form accompany any reports sent directly from clinicians.
Learning Disability Documentation Guidelines
- Disability Services request any and all recent documentation of the learning disability completed within the last three (3) years.
- The documentation must be based an evaluation from a professional specialist, i.e., licensed physician, psychiatrist, and/or education psychologist qualified to diagnose learning disabilities.
- The evaluation must minimally include the administration of a measure of intellectual ability (e.g., Wechsler Adult Intelligence Scales – 3rd Edition) and a measure of academic achievement (e.g., Wechsler Individualized Achievement Test – 2nd Edition, Woodcock Johnson Tests of Achievement, 3rd Edition). It is recommended that consideration be given to the presence of other medical or psychological conditions that mimic learning disabilities and/or that impair academic performance.
The documentation must include a written report that states the following:
- All tests administered.
- All test scores including I.Q. scores, factor scores, and subtest scores. Additionally, indication of the classification ranges associated with the scores should be present (e.g., average, high average, impaired).
- Diagnosis based upon established clinical criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders – 4th Edition).
- How the individual’s learning processes are affected.
- Concerns regarding the validity of the evaluation and its findings should be addressed. This would include factors such as limitations in the test’s norming sample, performance impairments resulting from co-morbid medical and psychological conditions, academic difficulties related to acculturation issues, and the client’s motivation for testing.
- Any recommendations for accommodations. The test findings should provide a logical rationale for the recommended accommodations.
Psychological Disability Documentation Guidelines
- The documentation must be submitted by a clinician who is qualified and appropriately licensed to diagnose and treat psychological disorders. Such a clinician is usually a psychologist, psychiatrist, or Marriage and Family Therapist.
- The evaluative methods used to establish the diagnosis should be indicated (e.g., clinical interview, psychological assessment battery).
- Test scores from measures of cognitive, neuropsychological, and academic functioning should be provided, if administered.
- A diagnosis consistent with established clinical criteria (e.g., DSM-IV) must be given.
- Indication of the person’s present symptoms and their degree of impairment (e.g., Global Assessment of Function score) should be provided.
- Information regarding how the person’s condition impacts him or her in an academic environment should be provided. This would include information about academic, personal, and interpersonal functioning.
- Recommendations for accommodations should be provided. The requested accommodations ought to logically flow from the diagnosis and the associated symptoms.
- Information about the person’s prognosis for improvement and the timeline for a reevaluation should be provided. Often many psychological conditions follow a transient course and improve with treatment and time; therefore annual reevaluations are generally required by the Office of Disability Services for persons receiving accommodations on the basis of psychological disability.
Physical / Medical Disability Documentation Guidelines
- The documentation should be provided by a clinician qualified and appropriately licensed to diagnose and treat physical and medical disorders. Such persons are usually physicians and other health specialists.
- A diagnosis of a physical or medical condition consistent with established clinical criteria must be given.
- The documentation should indicate the functional impact that the physical or medical condition has upon the person in an academic environment (e.g., attendance, stamina, fatigue, mobility, work completion).
- Information regarding the nature and course of the physical or medical condition should be provided (e.g., chronic, intermittent, and situational).
- Recommendations for accommodations should be made that logically flow from the person’s condition and associated difficulties.
- Information regarding the need for a reevaluation should be provided.
Privacy of Records
All student files and records are maintained in accordance with the requirements of the Family Educational Rights and Privacy Act of 1974 (FERPA).
Clinical information provided in the professional documentation of disability includes the diagnosis of a physical, learning, or psychological condition, related test scores, and supplemental information provided by a licensed health care or mental health care professional. Clinical information will not be released to anyone without the consent of the student except as necessary to implement accommodations or as needed for clinical consultation by the Coordinator of Disability Services. Access to clinical information is restricted to the Coordinator of Disability Services, the Vice President of Student Affairs, and the Director of the Counseling Center.
Additionally, the Counseling Center maintains independent records and may not release verbal or written information about a present or former patient or client without a written release of information from the patient or client unless required by law. Clinical documentation provided directly to Disability Services from a clinician is considered property of the clinician and will not be released to the student without the consent of the clinician.
Faculty and staff notification of disability status and accommodations will occur only at the request of the student. Except for the persons listed above, faculty and staff are not informed of the student’s diagnosis of disability. Requests for faculty and staff notification will generally involve the student’s completion of the Request for Disability Services Accommodation Form (see page 29 of Student Disability Services Handbook for the form). However, in some instances, a student may verbally request that the Coordinator of Disability Services contact a faculty of staff member on his or her behalf. Any verbal requests for information release will be documented in the student’s Disability Services file. In most cases, the Coordinator of Disability Services will inform the Provost’s office of any accommodations given to the student and by a letter addressed to the faculty or staff member and given to the student for distribution.
Release of Information to Disability Services
Health and mental health service providers must include a copy of the student’s signed Release of Information (see page 33 of Student Disability Services Handbook for the form) when providing information to Disability Services. Consistent with Section 56.11 of the California Civil Code, the signed release should:
- Be handwritten or typed in font greater than 8 point.
- State the specific uses and limitations on the types of medical information to be disclosed.
- State the name and function of the healthcare provider that may disclose the medical information.
- State the names and functions of the persons or entities authorized to receive the medical information.
- State the specific uses and limitations on the use of the medical information by the persons or entities authorized to receive the medical information.
- State a specific date after which the health care provider is no longer authorized to disclose the medical information.
- Advise the person signing the authorization of the right to receive a copy of the authorization.
Release of Clinical Documentation to Students
Under FERPA, students have the right to access and view their files. Students requesting to obtain copies of their clinical documentation from Disability Services must contact the Coordinator of Disability Services (see page 33 of Student Disability Services Handbook for the form). Documentation provided directly from the student to Disability Services will be released to the student. Documentation provided directly to Disability Services from a health or mental health clinician will not be released to the student without authorization from the clinician. Students wishing to obtain documentation provided directly from a clinician are to contact the clinician to request the documentation.
Release of Clinical Documentation to Third Parties
Students wishing to have documentation sent to third parties (e.g., clinicians, Vocational Rehabilitation, Educational Testing Services, other universities) must make a request to the Coordinator of Disability Services in writing and sign a release of information form available from Disability Services (see page 33 of Student Disability Services Handbook for the form). Documentation will only be released to persons and/or entities that are considered appropriate recipients of the information. When released, the documentation will be sent directly to the third party. If the documentation release is for the purposes of receiving accommodations on standardized tests (e.g., GRE) or for purposes of receiving accommodations at another academic institution, Disability Services reserves the right to inform the recipient of the student’s accommodation history at Vanguard University.
Security of Records
All student files and records related to disability accommodations will be kept in a secure filing cabinet maintained by the Coordinator of Disability Services in the Counseling Center.
While students may access and view their Disability Services file, photocopying of the file is discouraged in most cases. Should a student desire to photocopy the contents of his/her file, a written request must be made to Disability Services. Additionally, please know that under FERPA, students have the right to inspect, but not necessarily to copy, their records.