Traumatic Brain Injury (TBI)

Documentation Guidelines

All reports should be current and typed on letterhead, dated, and signed.

The following should be included in the report:
  1. Student information including name, date of most recent evaluation
  2. Evaluator name, title, and credentials
  3. History to Support Diagnosis
    • A description of the duration and severity of the injury
    • Last contact with individual, date of onset, and symptoms
  4. Evidence of current impairment
    • Description of how injury current impacts the student in social, academic, or occupational settings
    • Description of how the injury will limit the student in the classroom
  5. Assessment Information
    • Results and interpretation of assessment addressing student’s cognitive abilities, including processing speed and memory (post-rehabilitation and within one year)
    • Results and interpretation of any achievement testing conducted including scores and subscores
  6. Treatment and Medication
    • Description of any current medication, therapy, or other treatment being implemented
    • Description of the impact medication may have on student’s ability to perform in an academic environment
  7. Diagnosis
    • Clear statement of diagnosis including the DSM-5 or ICD-10 diagnostic code
  8. Recommended Accommodations
    • Include specific recommendations for academic accommodations and the rationale for the accommodations
Please return the report or address questions regarding documentation to:
Disability Support Services
University of Alabama at Birmingham
9th Ave Office Building, Suite 100
1720 2nd Ave S.
Birmingham, AL 35294-1413
Phone (205) 934-4205
TDD (205) 934-4248
Fax (205) 934-8170
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