Maryland Concussion Awareness Parent/Student-Athlete Acknowledgement Statement Form Download Printable PDF

For official use only:

Name of Athlete_____________________

Sport/season________________________

Date Received_______________________

Concussion Awareness

Parent/Student-Athlete Acknowledgement Statement

I ______________________________, the parent/guardian of ______________________,

Parent/Guardian

Name of Student-Athlete

acknowledge that I have received information on all of the following:

 The definition of a concussion

 The signs and symptoms of a concussion to observe for or that may be reported by my athlete

 How to help my athlete prevent a concussion

 What to do if I think my athlete has a concussion, specifically, to seek medical attention right

away, keep my athlete out of play, tell the coach about a recent concussion, and report any

concussion and/or symptoms to the school nurse.

Parent/Guardian_________________ Parent/Guardian___________________ Date ________

PRINT NAME

SIGNATURE

Student Athlete__________________ Student Athlete____________________ Date ________

PRINT NAME

SIGNATURE

It’s better to miss one game than the whole season.

For more information visit: www.cdc.gov/Concussion.

For official use only:

Name of Athlete_____________________

Sport/season________________________

Date Received_______________________

Concussion Awareness

Parent/Student-Athlete Acknowledgement Statement

I ______________________________, the parent/guardian of ______________________,

Parent/Guardian

Name of Student-Athlete

acknowledge that I have received information on all of the following:

 The definition of a concussion

 The signs and symptoms of a concussion to observe for or that may be reported by my athlete

 How to help my athlete prevent a concussion

 What to do if I think my athlete has a concussion, specifically, to seek medical attention right

away, keep my athlete out of play, tell the coach about a recent concussion, and report any

concussion and/or symptoms to the school nurse.

Parent/Guardian_________________ Parent/Guardian___________________ Date ________

PRINT NAME

SIGNATURE

Student Athlete__________________ Student Athlete____________________ Date ________

PRINT NAME

SIGNATURE

It’s better to miss one game than the whole season.

For more information visit: www.cdc.gov/Concussion.

For official use only:

Name of Athlete_____________________

Sport/season________________________

Date Received_______________________

PRE-PARTICIPATION HEAD INJURY/CONCUSSION

REPORTING FORM FOR EXTRACURRICULAR ACTIVITIES

This form should be completed by the student’s parent(s) or legal guardian(s). It must be submitted to the

Athletic Director, or official designated by the school, prior to the start of each season a student’ plans to

participate in an extracurricular athletic activity.

Student Information

Name:

Grade:

Sport(s):

Home Address:

Has student ever experienced a traumatic head injury (a blow to the head)?

Yes______ No______

If yes, when? Dates (month/year): ____________________________________

Has student ever received medical attention for a head injury? Yes_______ No________

If yes, when? Dates (month/year): ____________________________________

If yes, please describe the circumstances:

Was student diagnosed with a concussion? Yes________ No_______

If yes, when? Dates (month/year): ____________________________________

Duration of Symptoms (such as headache, difficulty concentrating, fatigue) for most recent concussion:

Parent/Guardian: Name: _______________________________(Please print)

Signature/Date _________________________________

Student Athlete: Signature/Date _______________________________________________________

For official use only:

Name of Athlete_____________________

Sport/season________________________

Date Received_______________________

Medical Clearance for Suspected Head Injury

To be completed by a Licensed Health Care Provider (LHCP)

Directions: Provide this form to the health care provider evaluating the student’s injury. Return form to school nurse immediately.

If the student is diagnosed with a concussion, the form will be copied by the school nurse and the original form returned to the

parent to use at the follow-up visit that clears the student for participation in athletics.

Student Name:____________________________________________________________

Date of Injury: ____________________________________________________________

Initial Evaluation

Date:______________ LHCP* Name: _______________________________________________

Signature:_________________________________________

Phone: _____________________



Diagnosis:

No Concussion, may immediately resume all activities without restriction



Concussion *

Date student may return to school: _________

Note: Student will be removed from all sports and physical education activities

at school until medically cleared. School will implement standard academic accommodations unless

specific accommodations are requested.

* (LHCP is a Physician, Nurse Practitioner, Physician’s Assistant, Neuropsychologist)

*Follow-Up Evaluation (Required for Athletes with Concussions)

All student athletes with concussions must be medically cleared before beginning supervised Gradual Return to Sports

/Physical Education Participation (RTP) program. According to COMAR 13A.06.08.01, the following licensed health care

providers are permitted to authorize a student athlete to return to play:

(1) A licensed physician trained in the evaluation and management of concussions;

(2) A licensed physician’s-assistant trained in the evaluation and management of concussions in collaboration with the physician

assistant’s supervising physician or alternate supervising physician within the scope of the physician assistant’s Delegation

Agreement approved by the Board of Physicians;

(3) A licensed nurse practitioner trained in the evaluation and management of concussions;

(4) A licensed psychologist with training in neuropsychology and in the evaluation and management of concussions; or

(5) A licensed athletic trainer trained in the evaluation and management of concussions, in collaboration with the athletic trainer’s

supervising physician or alternate supervising physician and within the scope of the Evaluation and Treatment protocol

approved by the Board of Physicians.

I certify that I am aware of the current medical guidance on concussion evaluation and management; the above-named student-

athlete has met all of the criteria for medical clearance for his/her recent concussion, and as of the date below is ready to return to a

supervised Gradual Return to Sports/Physical Education Participation (RTP) program (lasting a minimum of 5 days.)

Note: Students

whose symptoms return during the RTP progression will be directed to stop the activity, rest until symptom free. The student will resume activity at the previous stage

of the protocol that was completed without recurrence of symptoms. Students with persistent symptom return will be referred to their health care provider for

evaluation.

Date:______________ LHCP Name:

_______________________________________________

Signature:_________________________________________

Phone: _____________________

2010 AAP Sport-Related Concussion in Children and Adolescents, 2008 Zurich Concussion in Sport Group Consensus.

For official use only:

Name of Athlete_____________________

Sport/season________________________

Date Received_______________________

Graduated Return to Play Protocol

Description of Stage

Date Completed

Supervised by

STAGE 1: LIGHT AEROBIC ACTIVITY

Begin stage 1 when: Student is cleared by health care provider and has

no symptoms

Sample activities for stage 1: 20-30 minutes jogging, stationary bike or

treadmill

STAGE 2: HEAVY AEROBIC AND STRENGTH ACTIVITY

Begin stage 2 when: 24 hours have passed since student began stage 1

AND student has not experienced any return of symptoms in the previous

24 hours

Sample activities for stage 2: Progressive resistance training workout

consisting of all of the following:

•

4 laps around field or 10 minutes on stationary bike, and

•

Ten 60 yard springs, and

•

5 sets of 5 reps: Front squats/push-ups/shoulder press, and

•

3-5 laps or walking lunges

STAGE 3: FUNCTIONAL, INDIVIDUAL SPORT-SPECIFIC DRILLS WITHOUT

RISK OF CONTACT

Begin stage 3 when: 24 hours have passed since student began stage 2

AND student has not experienced any return of symptoms in the previous

24 hours

Sample activities for stage 3: 30-45 minutes of functional/sport specific

drills coordinated by coach or athletic trainer. NOTE: no heading of soccer

ball or drills involving blocking sled.

STAGE 4: NON-CONTACT PRACTICE

Begin stage 4 when: 24 hours have passed since student began stage 3

AND student has not experienced any return of symptoms in the previous

24 hours

Sample activities for stage 4: Full participation in team’s regular strength

and conditioning program. NOTE: no heading of soccer ball or drills

involving blocking sled permitted.

STAGE 5: FULL-CONTACT PRACTICE AND FULL PARTICIPATION IN

PHYSICAL EDUCATION

Begin stage 5 when: 24 hours have passed since student began stage 4

AND student has not experienced any return of symptoms in the previous

24 hours

Sample activities for stage 5: Unrestricted participation in practices and

physical education

STAGE 6: RETURN TO GAME

Begin stage 6 when: 24 hours have passed since student began stage 5

AND student has not experienced any return of symptoms in the previous

24 hours

For official use only:

Name of Athlete_____________________

Sport/season________________________

Date Received_______________________

Appropriate Educational Accommodations

Post-Concussion

Functional School

Accommodation/ Management Strategy

Effect

Problem

Short focus on lecture, class work,

Shorter assignments, break down tasks,

Attention/ Concentration

homework

lighter work load

Holding instructions in mind, reading

Repetition, written instructions, use of

“Working” Memory

comprehension, math calculation,

calculator, short reading passages

writing

Memory Consolidation/

Retaining new information, accessing

Smaller chunks to learn, recognition cues

Retrieval

learned info when needed

Keep pace with work demand,

Extended time, slow down verbal info,

Processing Speed

process verbal information effectively

comprehension-checking

Decreased arousal/ activation to

Rest breaks during classes, homework, and

Fatigue

engage basic attention, working

exams

memory

Headaches

Interferes with concentration

Rest breaks

Wear sunglasses, seating away from bright

Symptoms worsen in bright or loud

sunlight or other light. Avoid noisy/

Light/Noise Sensitivity

environments

crowded environments such as lunchroom,

assemblies, hallways.

Dizziness/Balance Problems

Unsteadiness when walking

Elevator pass, class transition prior to bell

Decreased arousal, shifted sleep

Sleep Disturbance

Later start time, shortened day

schedule

Can interfere with concentration;

Reassurance from teachers and team about

Anxiety

Student may push through symptoms

accommodations; Workload reduction,

to prevent falling behind

alternate forms of testing

Withdrawal from school or friends

Depression/Withdrawal

Time built in for socialization

due to stigma or activity restrictions

See specific cognitive accommodations

Cognitive Symptoms

Concentrating, learning

above

Reduce cognitive or physical demands

Symptoms worsen with over-activity,

below symptom threshold; provide rest

Symptom Sensitivity

resulting in any of the above

breaks; complete work in small

problems

increments until symptom threshold

increases

Source: Sady, M.D., Vaughan, C.G. & Gioia, G.A. (2011) School and the Concussed Youth: Recommendations for Concussion

Education and Management. Physical Medicine and Rehabilitation Clinics of North America. 22, 701-719. (pp.714)

"Concussion Awareness Parent/Student-Athlete Acknowledgement Statement Form" - Maryland

Download "Concussion Awareness Parent/Student-Athlete Acknowledgement Statement Form" - Maryland

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