Documentation Guidelines
All reports should be typed on letterhead, dated, and signed. Documentation should be no more than three years old. The following should be included in the report:
I. Student information including name, date of most recent evaluation
II. Evaluator name, title, and credentials
III. History to Support Diagnosis
a. A description of the duration and severity of the injury
b. Last contact with individual, date of onset, and symptoms
IV. Evidence of current impairment
a. Description of how injury current impacts the student in social, academic, or occupational settings
b. Description of how the injury will limit the student in the classroom
V. Assessment Information
a. Results and interpretation of assessment addressing student’s cognitive abilities, including processing speed and memory (post-rehabilitation and within one year)
b. Results and interpretation of any achievement testing conducted should include scores and subscores
VI. Treatment and Medication
a. Description of any current medication, therapy, or other treatment being implemented
b. Description of the impact medication may have on student’s ability to perform in an academic environment
VII. Diagnosis
Clear statement of diagnosis including the DSM-IV-TR or ICD-10 diagnostic (numerical) code
VIII. 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
HUC 516
1530 3rd Avenue South
Birmingham, AL 35294-1150
Phone (205) 934-4205
TDD (205) 934-4248
Fax (205) 934-8170