Head Injuries/Traumatic Brain Injuries
Documentation Guidelines

(The following guidelines were developed with the assistance of the Association on Higher Education and Disability and the Colorado University Disability Services office)

Evaluator’s Qualifications:

Head injury or traumatic brain injuries are considered medical or clinical diagnoses.  Individuals qualified to render a diagnosis for these disorders are practitioners who have been trained in the assessment of head injury or traumatic brain injury.  Recommended practitioners may include physicians; neurologists; licensed clinical, rehabilitation, or school psychologists and neuropsychologists and psychiatrists.

It is not considered appropriate for professionals to evaluate members of their families.  Documentation from a family member will not be accepted.

Reports from the professional should be submitted on letterhead and include the following:

• Name, title, and professional credentials of the evaluator
• Information about license or certification as well as the area of specialization
• Number of years employed in current field
• State/province in which the individual practices

Documentation:

Documentation should include the following:

1. A clear statement of the head injury or traumatic brain injury and the probable site of lesion.
2. Documentation for eligibility should be current, and should include information about condition, the current status of the student, and the student’s specific request for accommodations.
3. A summary of cognitive and achievement measures including standardized scores or percentiles used to make the diagnosis.
4. A summary of present residual symptoms that meet the criteria for diagnosis.
5. Medical information relating to student’s needs to include the impact of medication on the student’s ability to meet the demands of the postsecondary environment.
6. Suggestions of reasonable accommodations that might be appropriate at the postsecondary level.