Checklist for Documentation of ADHD  
   

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Dear Doctor:  

The Board of Regents of the University System of Georgia require that the following criteria, consistent with the DSM-IV, be met in documenting ADHD in adults. Without such written documentation, a student will be unable to receive appropriate academic accommodations that may be critical for his/her success. If you prefer to use this form rather than a narrative report, please indicate each criterion that is applicable to this student, and attach supporting data (e.g., copies of rating scales). 

Note: All documentation must include a specific diagnosis of ADHD and provide the evidence used to meet the seven criteria listed below. It is important for all evaluations to state clearly how ADHD functionally impacts the student's life across settings, creates a substantial limitation in learning. A clear rationale must be provided as to why specific accommodations are needed to mediate the impact of ADHD.

Student's Name: _______________________________          Student's Birth Date: _____________________

 

  1. Developmental history that is documented, using independent sources, of appropriate symptoms and problem behaviors across multiple settings.  Possible data sources: past evaluations, school records, teacher report

    Cite evidence obtained and its source:
  1. Documentation of current symptoms that meet diagnostic criteria.Possible data sources: clinical interview, behavior rating scales

Cite evidence obtained and its source:
  1. Documentation of both childhood and current adult behavior on ratings scales of ADHD symptoms that have appropriate age norms.  Possible data sources: Norms-based behavior rating scales

    Cite evidence obtained and its source:
  1. Corroboration of current ADHD symptoms across multiple settings by two independent observers with knowledge of the student's functioning.  Possible data sources: parent, spouse, teacher, supervisor, co-worker, relative, and/or clinician observation

    Cite evidence obtained and its source
  1. Clear evidence and documentation of interference with developmentally appropriate academic, social, or vocational functioning

    Cite evidence obtained and its source:
  1. All other psychiatric or medical disorders which may cause problems with inattention are differentially evaluated, documented, and considered in the differential diagnosis. This is particularly important when mood, anxiety, or substance abuse disorders are involved. Other causes of problems with attention and concentration must be considered and discussed (e.g., test anxiety). A positive response to medication is not by itself considered diagnostic.

    Cite evidence obtained and its source:
  1. Assessment on which the documentation is based must have been completed no more than three years prior to the student's application for academic assistance, OR must have been completed as an adult (18 years old or older) and still be considered current.
 
Date of assessment:
Diagnosis:
Current medications:
Additional information:
Signature: Date:
Name:
Address :
Office Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
 
 
 
 
 
 
 
 
 
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