Guidelines for documenting brain injury

A qualified evaluator

Professionals using assessments to determine the diagnosis of a traumatic brain injury and making recommendations for appropriate accommodations must be qualified to do so. This may be a medical doctor who specializes in neurological impairments, orthopedics, ophthalmology, neuropsychology, or another related field. A qualified evaluator may also need to provide the results of a psycho-educational test battery for individuals with acquired brain injury. The documentation must meet the following criteria:

  • Include evaluator’s name, title and professional credentials.
  • Be typed, dated and signed on the professional’s letterhead.
  • Evaluator may not be a family member.


Must be current: The impact of a traumatic brain injury (TBI) can be mild or severe. Recovery from a TBI varies based on the individual and the brain injury. To determine the most appropriate accommodations, traumatic brain injury documentation must be current within the past three years unless the disability is of a physical or sensory nature and is permanent or unchanging.

Must be comprehensive: A brain injury can be complex with a broad spectrum of symptoms and disabilities and can be categorized as mild or severe. Documentation must include:

  • A clear history and statement of the diagnosis
  • Evaluations by a neurologist, neuropsychologist, physical therapist, occupational therapist, speech therapist or other qualified professional that assess the specific deficits and provide a full description of the current difficulties and functional limitations.
  • Evaluations documenting the disability should include test instruments used with dates administered and results including all subtest and percentile scores.
  • A narrative that discusses the severity of each limitation and the impact of these limitations on learning and functioning in the academic environment.
  • Suggestions of reasonable accommodations which are supported by the diagnosis

May include supporting information: In addition to the current reports of qualified evaluators, it is also helpful to have reports of the following:

  • Previous accommodations. 
  • Past school reports, including IEP or 504 plans.
  • Any other past medical evaluations.