Documentation Guidelines for Traumatic Brain Injury (TBI)
Head injury is one of the fastest growing types of disabilities, especially in the age range of 15 to 28 years. There is a wide range of differences in the effects of TBI on the individual, but most cases result in some type of impairment. The functions that may be affected include the following: memory, communication, cognitive/perceptual communication, speed of thinking, spatial reasoning, conceptualization, psychosocial behaviors, motor abilities, sensory perception, and physical abilities.
The following guidelines are provided to assist the college in collaboration with each student to determine appropriate accommodations. Documentation serves as a foundation to legitimize a student’s request for appropriate accommodations. Documentation from family members, immediate or otherwise, is not acceptable. A school plan such as an Individualized Educational Plan [IEP] or a 504 Plan is NOT sufficient documentation.
Recommended documentation includes:
- A clear statement and classification of the head injury or traumatic brain injury including date of injury and classification and dates pertaining to history of multiple concussions (as applicable).
- Documentation should reflect the current level of functioning and is dependent upon the disabling condition, the current status of the student and the student’s request for reasonable accommodations).
- A summary of cognitive and achievement measures used and evaluation results (neuropsychological report) including standardized scores or percentiles used to make the diagnosis.
- A summary of current residual symptoms and cumulative damage (as applicable and as a result of repeated injuries) which meet the criteria for diagnosis.
- Medical information relating to the student’s needs should include the impact of treatments, medications, devices or services currently prescribed.
- Suggestions of reasonable accommodation(s) which might be appropriate at the postsecondary level are encouraged. These recommendations should be supported by the diagnosis.