Head Injury/Traumatic Brain Injury

Documentation Guidelines

In order to fully evaluate requests for accommodations or auxiliary aids and to determine eligibility for services, Student Disability Services (SDS) needs documentation of your disability. The documentation you provide should include an evaluation by an appropriately licensed professional who has direct experience in working with an adult population. The documentation must make evident the current impact of the disability as it relates to the accommodation(s) requested and include a description of any and all functional limitations.

Head injury or traumatic brain injury is considered a medical and/or clinical diagnosis. Individuals qualified to render a diagnosis for these disorders are practitioners who have been trained in the assessment of head injury or traumatic brain injury. Recommended practitioners include physicians, neurologists, licensed rehabilitation and/or school psychologists, neuropsychologists and psychiatrists. Such documentation should be on letterhead and contain the professional's signature and license number. The evaluator must be impartial and not related to the person being evaluated.

The general guidelines listed below are developed to assist you in working with your treating/diagnosing professional(s) to prepare the information needed to evaluate your request(s). If, after reading these guidelines and reviewing disability specific information provided below, you have any questions, feel free to call Student Disability Services at 210-458-4157.

Documentation

In order to receive services from SDS, documentation must be submitted in advance. Documentation validates the functional limitations, which allows consideration for accommodation requests. The currency of documentation is dependent upon the disabling condition, the current status of the student and the student's request for accommodations. Thus, if the head injury leads to a disabling condition that is progressive, SDS would ask for documentation within the last two years. Documentation for non-progressive cognitive disorders should be within the last five years or less. However, each request will be evaluated on a case by case basis. Documentation should include but is not limited to:

  • A clear diagnostic statement of a head injury or traumatic brain injury and the probable site of lesion with supporting data.

  • A summary of cognitive and achievement measures used and/or evaluation of symptoms which would include standardized scores or percentiles and which meet the criteria for diagnosis of a cognitive disorder resulting from the head injury. (Note: The student may be required to submit a neuropsychological evaluation by a neuropsychologist depending upon the types of accommodations they request.)

  • Medical information relating to the student's needs and the status of the student's impairment(static or changing) and its impact on the demands of the academic program.

  • Narrative or descriptive text providing both quantitative and qualitative information about the student's abilities which might be helpful in understanding the student's profile, including the use of any auxiliary aids and/or ongoing therapy (if appropriate).

  • A statement of the functional impact or limitation of the disability on learning or other major life activity and the degree to which it impacts the individual in the learning context for which accommodations are being requested.

  • Suggestions of reasonable accommodation(s) which might be appropriate at the post secondary level are encouraged. These recommendations should be supported by the diagnosis.

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 the provision of a like accommodation. Student Disability Services will make the final determination as to whether appropriate and reasonable accommodations are warranted and can be provided to the individual.

All documentation submitted to Student Disability Services is considered to be confidential under FERPA guidelines. Documentation should be sent to the following address:

University of Texas at San Antonio
Student Disability Services
One UTSA Circle, MS 3.01.16
San Antonio, Texas 78249-0690

210-458-4157 (voice-Main)
210-591-7318 (Videophone)