Head Injury/Traumatic Brain Injury Documentation Guidelines
The student is responsible for providing documentation that supports
his/her request for accommodation. It is important that the documentation
clearly establishes that the student has a disability as defined by federal
regulations and that the documentation clearly supports the individual's
request for accommodation. The following documentation guidelines are
provided in the interest of ensuring that documentation of Head Injury/Traumatic
Brain Injury demonstrates a significant impact on a major life activity
and supports the individual's request for accommodation.
- A Qualified P rofessional must
conduct the evaluation: It is important that the evaluator
have comprehensive training and direct experience with adolescents
and adults with traumatic brain injury, such as a licensed psychologist
, or neuropsychologist or rehabilitation specialist in brain injury.
The name, title and professional credentials of the evaluator, including
information about license or certification and employment should be
clearly stated in the documentation. All reports should be on letterhead,
dated, signed and otherwise legible.
- Documentation sh ould
be current: The provision of accommodations is based upon
assessment of the current impact of the student's disabilities on his
or her academic performance and learning style. Documentation that
is outdated or inadequate in scope of content; does not address the
student's current level of functioning; does not address changes in
the student's performance since the previous assessment was
conducted; or was done before the student was one year post injury may
be inadequate to support requeste d accommodations. When appropriate, additional
supportive documentation will be requested.
- Documentation
necessary to substantiate a disability should include:
- Diagnostic interview with report describing presenting problems,
medical, psychosocial, or dual diagnosis where indicated;
- Assessment
of aptitude post injury with all sub-tests and standard scores
reported;
- Achievement measures since injury with all sub-tests
and standard scores reported;
- A summary of present residual symptoms
, which meet the criteria for diagnosis;
- Medical information
relating to student's needs should include the impact of medication
on the student's ability to meet the demands of the postsecondary
environment;
- A statement of the functional impact or limitation
of the disability on learning or other major life activity and
the degree to which it impacts the individual in the learning context
for which the accommodations are being recommended;
- Information
processing style with test scores and r ecommendations in the
learning environment.
- Interpretative Summary based on comprehensive evaluative
process: An interpretative summary should include a demonstration
of the evaluator's having ruled out alternative explanations for
academic problem s (e.g. poor education, poor motivation, emotional
problems, attentional problems and cultural/language differences);
indication of patterns in the student's cognitive ability, achievement,
and/or information processing reflecting the presence of a learning
disability; indication of the substantial limitation to learning
or other major life activity presented by the disability and the degree
of impact in the learning context; indication of why specific accommodation
or auxiliary aids are needed and specific conditions under which
they were used in the past. Medical information, as appropriate,
should include the impact of medication on the student's ability
to meet the demands in a post-secondary environment.
- Recommendations for Accommodations:
- Include specific recommendations and rationale for accommodations;
- Include a description of the impact of the diagnosed TBI on specific
major life activities;
- Recommendations should be supported by specific
test results and/or clinical observations that the accommodation
has been effective.
Last Modified:
January 12, 2007
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