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

This fillable "Concussion Awareness Parent/Student-Athlete Acknowledgement Statement Form" is a document issued by the Maryland State Department of Education specifically for Maryland residents.

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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: _____________________
1
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)

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