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Documentation Guidelines for Head Injury/Traumatic Brain Injury



Head Injury and Traumatic Brain Injury 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 a Head Injury or Traumatic Brain Injury. Recommended practitioners may include physicians; neurologists; licensed clinical, rehabilitation and school psychologists; neuropsychologists and psychiatrists. The diagnostician must be an impartial individual who is not a family member of the student.

The following documentation requirements will assist the service provider in collaborating with each student to determine appropriate accommodations. Documentation serves as a foundation that supports a student's request for appropriate accommodations. Recommended documentation includes all of the following:

  1. A clear statement of the head injury or traumatic brain injury, the probable site of lesion, and the date of injury,
  2. Documentation for eligibility must reflect the current impact the head injury has on the student's functioning; (the age of acceptable documentation is dependent upon the disabling condition, the current status of the student and the student’s specific request for accommodations);
  3. A summary of cognitive and achievement measures used and evaluation results including standardized scores used to make the diagnosis;
  4. A summary of present residual symptoms which meet the criteria for diagnosis
  5. Medical information relating the student’s needs must include the impact of medication on the student's ability to meet the demands of the postsecondary environment
  6. A statement of the functional impact or limitations of the disability on learning or other major life activities and the degree to which it impacts the individual in the learning context for which accommodations are being requested.
  7. Further assessment by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated. The student and the Disability Specialist at the University of Colorado Denver will collaborate regarding accommodations with the final decision made by the disability specialist.

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