Documentation Guidelines: Traumatic Brain Injuries

Colored brainStudents seeking support services from Student Accessibility Services (SAS) 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 SAS staff to make appropriate decisions. Please do not hesitate to contact SAS at 956-882-7374 on the Brownsville campus or 956-665-7005 on the Edinburg campus 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, and other medical conditions) must submit evidence of a disabling condition with evidence of functional impairment in major life activities of relevance to the classroom.  

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 3 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 should include current treatment regimens and medications (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.

All documentation must be submitted on the official letterhead of the professional describing the disability. The report should be dated and signed and include the name, title, and professional credentials of the evaluator, including information about license or certification. Evaluators should not be related to the individual being assessed.

Student Accessibility Services will make the determination regarding whether accommodations are reasonable in the University environment. 

All documentation submitted to SAS is considered confidential.