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 on the basis of a traumatic brain
injury (TBI) or
brain insult must provide documentation by a neuropsychologist. Documentation
must
be current: within the past 3 years for a high school student and
within the past 5 years
for an adult. A school plan such as an IEP or 504 Accommodation Plan
is insufficient
documentation. All testing instruments must be standardized for use
on adults.
Documentation must include, but is not limited to, the following:
1. A thorough neuropsycholgical 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.
2. Evidence of current impairment
Documentation should discuss history of the individual’s presenting
symptoms
and evidence of behaviors that significantly impair functioning.
3. Diagnostic interview
Must contain self-report and third-party information pertaining to:
(a) developmental history
(b) family history
(c) learning or psychological difficulties
(d) relevant medical history
(e) a thorough academic history
4. Evidence that alternative diagnoses or explanations were ruled
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 as
a result of the injury).
5. Diagnosis
Include a specific statement of diagnosis, as well as the corresponding
DSM-IVTR
code.
Documentation Requirements
TBI (p. 2)
6. Clinical Summary
Must address:
(a) The substantial limitations to major life activities posed by
the disability.
(b) A description of the extent to which these limitations would impact
the
academic context for which accommodations are being requested.
(c) Suggestions as to how the specific effects of disability may be
accommodated.
(d) 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. *
7. Additional Requirements
(a) Interpretation of test results is required. Test protocol sheets,
handwritten
summary sheets or scores alone are not sufficient.
(b) 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.
* A history of accommodations does not in itself warrant the provision
of similar
accommodations at UA. The final determination of appropriate and reasonable
accommodation rests with the University of Alabama.
Please forward all documentation to:
Office of Disability Services
University of Alabama
133B Martha Parham East
Box 870185
Tuscaloosa, AL 35487-0185
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, 6/2004
