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documentation Guidelines for people with acquired brain and traumatic injuries

Students who are requesting support services from Disability Support Services at The University of North Carolina at Pembroke are required to submit documentation to verify eligibility under the ADA of 1990. The following guidelines are provided in the interest of ensuring that the documentation is complete and appropriate:

1. A specific statement of the injury and the probable site of lesion must be stated within the documentation submitted. If another diagnosis is applicable, it should also be stated. A statement should be included indicating the current status of the injury and any relevance to the institutional setting.

2. Disability Support Services encourages entering students to complete a full evaluation just prior to attending The University of North Carolina at Pembroke. If this is not possible, we encourage the evaluation to have been completed within the past three years for students just graduating high school.

3. It is preferred that individuals who are 17 years of age or older be tested using diagnostic instruments normed for adults. Documentation that is more than three years old will be considered individually. All documentation will be handled on a case-by-case basis, and students may be required to submit more recent documentation.

4. The evaluation must be performed by a professional who is knowledgeable about brain injuries and qualified to make appropriate recommendations. This would include a physician, neurologist, licensed clinical and rehabilitation psychologists, neuropsychologists, and psychiatrists. This documentation must be made and signed by a medical or mental health practitioner who is 1) not immediately related to the student and 2) licensed/certified in the area for which the diagnosis is made.

5. A summary consisting of cognitive and achievement measurements and evaluation results, including standardized scores or percentiles used to make the diagnosis must be included. The assessment, and any resulting diagnosis, should consist of and be based on a comprehensive assessment battery which does not rely on any one test or subtest. Evidence of a substantial limitation to learning or other major life activity must be provided. Both aptitude and academic achievement must be evaluated and included in the test report. The following tests are considered acceptable:

• Aptitude: WAIS-III; Stanford-Binet IV; Woodcock-Johnson Psychoeducational Battery Revised: Test of Cognitive Ability
• Academic Achievement: Woodcock-Johnson Psychoeducational Battery -Revised: Test of Achievement- Wechsler Individual Achievement Test (WIAT); Stanford Test of I Academic Skills (TASK); Scholastic Abilities Test for Adults (SATA)

* The Wide Range Achievement Test-3 (WRA T-3) is not a comprehensive measure of achievement and therefore should not be used as a sole measure of achievement.

6. Specific cognitive processing strengths, weaknesses, and deficits should be discussed. Clear documentation of deficit areas is necessary in order for the college to provide appropriate, reasonable accommodations. Please discuss the following processing areas:

• Visual spatial abilities
• Memory (auditory and visual; short-term and long term)
• Fine Motor/dexterity (speed/sequence of motor patterns)
• Executive functions (verbal and nonverbal reasoning). It is also helpful to know about the student's cognitive flexibility and automaticity with cognitive tasks.
• Selective attention/perception (auditory and visual)
  

7. A comprehensive evaluation by a speech-pathologist to determine oral language skills should be included. Formal instruments or an informal analysis of a language sample are appropriate.

8. Social-emotional status should be assessed and discussed. Formal assessment instruments and/or clinical interview are appropriate. If applicable, a mental health diagnosis should be clearly stated.

9. A statement of functional impact or limitations 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.

10. Medical information relating to the student needs to include the impact of medication on the student's ability to meet the demands of the post-secondary environment.

11. The documentation must include the following information:

• Names of the assessment instruments used
• Quantitative and qualitative information which supports the diagnosis
• The areas of educational impact and the severity of the condition
• Recommendations for prescriptive treatments
• Notation of medications prescribed, if any, and potential impact on learning
• Additional observations or recommendations which could assist us in adequately serving the student
• The names, titles, addresses, and phone numbers of the evaluator(s), as well as date(s) of testing

The aforementioned guidelines are provided so that Disability Support Services can respond appropriately to the individual needs of the student.

Disability Support Services reserves the right to determine eligibility for services based on the quality of the submitted documentation.

All documentation is confidential.

Please submit documentation and/ or inquiries to:
Mary Helen Walker, MA, NCC, NCLPC
Director, Disability Support Services
The University of North Carolina at Pembroke
Disability Support Services
PO Box 1510
Pembroke, NC 28372-1510
Phone/Voice: (910) 521-6695
Fax: (910) 521- 6891
TTY: (910) 521-6490
Email: dss@uncp.edu

08/02

 

Updated: Monday, March 14, 2005

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