Traumatic Brain Injury

Documentation Guidelines for Traumatic Brain Injury

Documentation must: 
1. Be completed by a qualified evaluator: Professional qualifications of those providing diagnoses, offering clinical judgments and making recommendations for accommodations for test takers with traumatic brain injuries must hold appropriate licensure/certification and have comprehensive training and relevant expertise in the specialty. In addition, the name, title and professional credentials of the evaluator should be included on letterhead, typed in English, dated and signed. Reference Section I of the policy statement. ETS acknowledges that documentation of this complex condition may be medically, psychologically, academically and/or vocationally oriented. In most cases, a neuropsychological or psychoeducational evaluation will be useful in clarifying the functional impact of the diagnosed disability and in supporting the underlying rationale for accommodations on a standardized test. Given the complexity of the traumatic brain injury diagnosis, the review process is highly individualized. 
2. Include test taker’s identifying information: Provide the test taker’s identifying information, including full name and date of birth. Reference Section I of the policy statement. 
3. Be current: It is important that the clinical information submitted to ETS for review should accurately reflect the applicant’s current functional status. Since further recovery can occur, the applicant’s accommodation needs are not necessarily fixed as of the date of the evaluation. The submitted functional profile should reflect the capacities of the test taker in a time frame that is relevant to the anticipated standardized test administration. If the head injury or trauma occurred within the last year, ETS needs current documentation. For those individuals whose injury occurred more than one year ago, documentation may be from within the last three years. Reference Section III of the policy statement. Individuals with traumatic brain injuries often experience co-occurring disabilities (i.e., “comorbidities”) such as Attention-Deficit/Hyperactivity Disorder (ADHD), learning disabilities (LD), psychiatric disabilities (e.g., PTSD, depression, anxiety, etc.), and/or physical disabilities or chronic health conditions (e.g., headaches, nausea, seizures, loss of bowel or bladder control, etc.). If a test taker has multiple diagnoses that may affect his or her ability to perform on test day, test takers and evaluators should consult the appropriate ETS documentation guidelines 
4. Provide specific diagnosis/diagnoses: Qualified professionals are encouraged to cite the specific objective measures used to help substantiate diagnoses. Reference Section II of the policy statement. Concussion and Post-Concussive Syndrome (PCS) are clinical subsets of traumatic brain injuries. Please see Appendix B, “Assessment Tools for Post-Concussive Syndrome.
5. Discuss the current functional limitations: This would include daily life activities in academic and/or employment environments, with the understanding that a traumatic brain injury presents across a variety of settings. Reference Section IV of the policy statement.
6. Discuss side effects the test taker experiences from prescribed medications and therapies. Reference Section IV of the policy statement. 
7. Include a rationale for each accommodation or device: Establish a link between the requested accommodations and the individual’s current functional limitations that is pertinent to the testing situation.