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Guidelines for Documenting Traumatic Brain Injury

Students seeking support services from Services for Students with Disabilities (SSD) on the basis of a previously diagnosed Traumatic Brain Injury (TBI) must submit documentation that verifies their eligibility under Section 504 of the Rehabilitation Act, the Americans with Disabilities Act (ADA) and the ADA Amendments Act. The documentation must describe a disabling condition, which is defined by the presence of significant limitations in one or more major life activities. Merely submitting evidence of a diagnosis, and/or a 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 individual “attention problems,” “academic problems,” and “test difficulty/anxiety” in and of themselves do not constitute a disability. The guidelines below are intended to provide guidance for the assessment process, including the areas that must be assessed in order for SSD staff to make appropriate decisions. Examples of specific tests that may be used within each area are available upon request. Please do not hesitate to contact SSD at (512) 471-6259 if you have any questions.


Students submitting documentation of physical and/or cognitive sequelae related to a traumatic brain injury (e.g., head trauma, CVA’s, tumors, other medical conditions) must submit evidence of a disabling condition with evidence of functional impairment in major life activities of relevance to the classroom.  Such documentation should include:
 

  1. DSM-IV or ICD Diagnosis (text and code): Detailed background information – including information obtained in diagnostic interviews, relevant hospital and/or rehabilitation records, history of premorbid functioning (including prior academic history and developmental history), any pertinent medical and psychological history, and a discussion of dual diagnosis, if present; this includes a history of any coexisting disorders that could affect functioning.

    As above, all testing/evaluation reports should be current (within the last three years), comprehensive, and have been conducted and signed by a qualified professional.  Qualified professional should not be related to the individual being assessed.

  2. Evaluation: Comprehensive neuropsychological evaluation – conducted after the injury, which includes, but is not limited to, the domains described above for learning and communication disorders.

     

  3. Functional Limitations: Evidence of current impairment, including behaviors that significantly affect functioning, and how these relate to academics should be provided. A discussion of estimated premorbid functioning should also be included.

    Detailed information regarding residual physical or medical impairments – current treatment regimens, including current medications.

    Functional limitations should be determined WITHOUT consideration of mitigating measures (i.e. medication, etc.).  If condition is episodic in nature, level of functioning should be assessed based on active phase of symptoms.

  4. Accommodations: Suggested recommendations, modifications and/or accommodations.

 

General Guidelines for all  Disabilities
It is important to recognize that accommodation needs can change over time and are not always identified during the initial diagnostic process. A prior history of accommodation, without demonstration of current need, does not in and of itself warrant provision of a like accommodation.

SSD will make the final determination as to whether appropriate and reasonable accommodations are warranted and can be provided to the individual.

In addition to documentation as described above, transfer students should provide written verification of accommodations received (and dates served) from the previously attended school(s).

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

 
 
All documentation submitted to SSD is considered confidential.  

Documentation should be sent to the following address:
 
The University of Texas at Austin
Division of Diversity and Community Engagement
Services for Students with Disabilities
1 University Station A4100
Austin, Texas 78712-0175
 
Documentation may be faxed to (512) 475-7730.
 

Click here for TBI Documentation Guidelines (PDF).


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