Brain Injury Documentation Guidelines

Traumatic brain injuries may include head trauma, cerebrovascular accidents (CVAs), tumors and other medical conditions. Merely submitting evidence of a diagnosis or discrepancy between ability and achievement on the basis of a single subtest score is not sufficient to warrant academic accommodations. Similarly, nonspecific diagnoses, such as “attention problems,” “academic problems,” and/or “test difficulty/anxiety” in and of themselves do not constitute a disability. Examples of specific tests that may be used within each area are available upon request.

All testing and evaluation reports should be current (within the last three years), comprehensive and have been conducted and signed by a qualified professional.

 

Background Information, including information obtained in

  1. Diagnostic interviews.
  2. Relevant hospital and/or rehabilitation records.
  3. History of premorbid functioning, including prior academic history and developmental history.
  4. Any pertinent medical and psychological history.
  5. Discussion of dual diagnosis, if present; this includes a history of any coexisting disorders that could affect functioning.

 

Comprehensive Neuropsychological Evaluation, conducted after the injury and including

  1. Domains described above for learning and communication disorders.
  2. Evidence of current impairment, for example behaviors that significantly affect functioning, and how these relates to academics.
  3. Discussion of estimated premorbid functioning.

 

Residual Physical or Medical Impairments, with current treatment regimens

 

Accommodations

  1. Suggested recommendations, modifications and/or accommodations.

 

The diagnostic report, must include the name, title and license number of the evaluator. A verification form is available to assist in the documentation process.