Traumatic Brain Injury

DOCUMENTATION REQUIREMENTS

UNIVERSITY OF ALABAMA

OFFICE OF DISABILITY SERVICES

TRAUMATIC BRAIN INJURY / BRAIN INSULT

 

(Trauma to the brain resulting from injury, cerebral vascular accidents, tumors, or other medical conditions)

 

Students requesting accommodations because of a traumatic brain injury (TBI) or brain insult must provide documentation by a qualified professional, a person who is licensed or otherwise properly credentialed and possesses expertise in the disability for which modifications or accommodations are sought. Documentation must provide evidence of a disability, and the evaluation must have occurred after the student reached the age of 13.

 

A school plan such as an IEP or 504 Accommodation Plan is insufficient documentation without the background information from which the plan was written.  Testing instruments normed for use with adults are preferred.  A history of accommodations does not in itself warrant the provision of similar accommodations at the UA.  The final determination of appropriate and reasonable accommodations rests with The University of Alabama.

 

  1. NEUROPYCHOLOGICAL EVALUATION

The assessment must address the areas of attention, visuoperception/visual reasoning, language, academic skills, memory/learning, executive function, sensory, motor and emotional status.  Data should include standard scores and percentiles.

 

  1. EVIDENCE OF CURRENT IMPAIRMENT

Documentation should discuss history of the individual’s presenting symptoms and evidence of behaviors that significantly impair functioning.

 

  1. DIAGNOSTIC INTERVIEW

Must contain self-report and third party information pertaining to:

  • developmental history
  • family history
  • learning or psychological difficulties
  • relevant medical history
  • a thorough academic history

 

  1. EVIDENCE OF ALTERNATIVE DIAGNOSES/EXPLANATIONS OF RULE OUT

 

The documentation must investigate and discuss the possibility of dual diagnoses and alternative or coexisting mood, learning, behavioral, and/or personality disorders that may confound the diagnosis.  Records of academic progress prior to the onset of the TBI must be reviewed to substantiate that the current level of functioning is a direct cause of the brain injury (i.e., that function has changed because of the injury).

 

  1. DIAGNOSIS

Include a specific statement of diagnosis, as well as the corresponding DSM-V code.

 

  1. CLINICAL SUMMARY

Must address:

  • The substantial limitations to major life activities posed by the disability.
  • A description of the extent to which these limitations would impact the academic context for which accommodations are being requested.
  • Suggestions as to how the specific effects of disability may be accommodated.
  • The rationale behind the suggested accommodations. Any recommendation for an accommodation should be based on objective evidence of a substantial limitation to learning, supported by specific test results and clinical observations.  In establishing the rationale for recommended accommodations, test data should be used to document the need.

 

  1. ADDITIONAL REQUIREMENTS
    • All reports must be in narrative format, typed, signed by the diagnosing clinician, and must include the names, titles and professional credentials of the evaluators as well as the date(s) of testing.
    • Documentation must be submitted on the official letterhead of the professional diagnosing the disability.
    • Chart or clinic notes are not acceptable as documentation.

 

Please forward all documentation to:

Office of Disability Services

University of Alabama

1000 Houser Hall

Box 870185

Tuscaloosa, AL 35487-0185

Email: ods@ua.edu

FAX (205) 348-0804

 

This document will be made available in alternative formats upon request.  Please contact the Office of Disability Services, (205) 348-4285 (Voice) or (205) 348-3081 (TTY) for assistance.

 

Revised 02/2018