Traumatic Brain Injury (TBI) Documentation

Head injury or traumatic brain injury is considered a medical 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; neurologist; licensed, clinical, rehabilitation and school psychologists; neuropsychologist and psychiatrists. The diagnostician must be an impartial individual who is not a family member of the student. In order to determine eligibility and to provide services, we require documentation of the student's condition.

Documentation assists the Office of Disability Services staff to:

Establish a student's eligibility for services.
Understand the impact of a student’s condition(s) in an academic environment.
Determine strategies and reasonable accommodations to facilitate equal access.

Further information on the components of professionally prepared documentation such as: qualified professionals; diagnostic statements; diagnostic methodology; current functioning and current documentation; functional impairment; duration, progression, and stability of a condition; and documentation to support requested reasonable accommodations can be found at the following link: General Documentation Principles and Guidelines . In addition to the requested information, additional relevant documentation can be attached at the end of this form. You will have the opportunity to print or save a copy of your submission at the conclusion of the form for your records. Please contact us if you have questions or concerns. Thank you for your assistance.

Student's First Name *

Student's Last Name *

Student's Date of Birth *

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Student's Street Address

Student's City

Student's State

Student's Zip Code

In order to help this student adapt to college life after his/her injury, please supply (in as much detail as possible) answers to the questions that follow. Please complete all items which you have a history or have assessed in the course of clinical evaluation. If you wish to, please attach any relevant reports. At the end of this form, please hit submit and attach any items.

Date of Injury

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Number of Concussions With Loss of Consciousness

Date of Loss of Consciousness

Number of Concussions Without Loss of Consciousness

Date(s) Without Loss of Consciousness

Hospitalization with any of these injuries?

Yes No

Surgery needed for any of these injuries?

Yes No

If you answered yes to any of the above, please provide details here:

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Traumatic Brain Injury (TBI) Documentation