Yes   No   The student has an acquired injury to the brain caused by external
                 physical force which substantially limits the student's functional or
                 psychosocial ability or both and the student's ability to learn or
                 participate in the general education curriculum.

Yes  No    Documentation of specific examples of the severe effect of the
                 injury on the student's educational performance, including school
                 attendance, loss or retention of previously acquired skills and
                 knowledge, and student's social/interpersonal skills.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

EXCLUSIONARY FACTORS:

The student may not be identified as having a traumatic brain injury if the
disability is primarily due to visual or hearing impairment, cognitive delay,
emotional disturbance, or if the injury to the brain is congenital, degenerative,
or caused by birth trauma.

DEFINITIONS:

"Substantially limits" means that the student's ability to learn and participate in
the general education setting remains severely affected even when classroom
interventions are applied or accommodations provided.

The term traumatic brain injury applies to open or closed head injuries resulting
in impairments in one or more areas such as cognition, language, memory,
attention, reasoning, abstract thinking, judgment, problem-solving, sensory,
perceptual, and motor abilities, psycho-social behavior, physical function,
information processing, and speech.

Student Name: _________________ CST Date: __________