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Concussion protocol informed consent form


This consent form was developed to provide students and parents with current and relevant information regarding concussions and to comply with Connecticut General Statutes (C.G.S.) Chapter 163, Section149b: Concussions:

What is a Concussion? National Athletic Trainers Association (NATA) - A concussion is a “trauma induced alteration in mental status that may or may not involve loss of consciousness.” Centers for Disease Control and Prevention (CDC) - “A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth.” -CDC, Heads Up: Concussion http://www.cdc.gov/headsup/basics/concussion_whatis.html Even a “ding,” “getting your bell rung,” or what seems to be mild bump or blow to the head can be serious” -CDC, Heads Up: Concussion Fact Sheet for Coaches http://www.cdc.gov/concussion/HeadsUp/pdf/Fact_Sheet_Coaches-a.pdf
 
Signs and Symptoms of a Concussion: Overview A concussion should be suspected if any one or more of the following signs or symptoms are present, or if the coach/evaluator is unsure, following an impact or suspected impact as described in the CDC definition above.

Signs of a concussion may include (i.e. what the athlete displays/looks like to an observer):
*Confusion/disorientation/irritability                              *Trouble resting/getting comfortable
*Lack of concentration                                                 *Slow response/drowsiness                     
*Headache or dizziness                                                *Incoherent/ slurred speech               
*Slow/clumsy movements                                            *Balance problems
*Loses consciousness                                                  *Amnesia/memory problems                   
*Nausea or vomiting                                                    *Acts silly/combative/aggressive             
*Repeatedly ask same questions                                  *Blurred or double vision
*Dazed appearance                                                    *Restless/irritable         
*Oversensitivity to sound/light/touch                           *Constant attempts to return to play     
*Constant motion                                                       *Disproportionate/inappropriate reactions

Symptoms of a concussion may include (i.e. what the athlete reports):
*Ringing in ears                                  *Feeling foggy or groggy

State law requires that a coach MUST immediately remove a student-athlete from participating in any intramural or interscholastic athletic activity who: a) is observed to exhibit signs, symptoms, or behaviors consistent with a concussion following a suspected blow to the head or body, or b) is diagnosed with a concussion, regardless of when such concussion or head injury may have occurred. Within 24 hours that the student athlete has exhibited signs and symptoms of a concussion, a coach will call a parent/guardian.
Currently, it is impossible to accurately predict how long an individual’s concussion will last. There must be full recovery before a student-athlete is allowed to resume participating in athletic activity. Connecticut law now requires that no athlete may resume participation until they have received written medical clearance from a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.

Concussion Management Requirements:
    1. No athlete SHALL return to participation in the athletic activity on the same day of concussion.

    1. If there is any loss of consciousness, vomiting or seizures, the athlete MUST be immediately transported to the hospital.

    1. Close observation of an athlete MUST continue following a concussion. The athlete should be monitored for an appropriate amount of time following the injury to ensure that there is no worsening/escalation of symptoms.

  1. Any athlete with signs or symptoms related to a concussion MUST be evaluated by a licensed health care professional
(Physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.
  1. The athlete MUST obtain an initial written clearance from one of the licensed health care professionals identified above directing her/him into a well-defined Return to Play (RTP) stepped protocol similar to the one outlined below. If at any time signs or symptoms return during the RTP progression, the athlete should cease activity*
  1. After the RTP protocol has been successfully administered (no longer exhibits any signs or symptoms or behaviors consistent with concussions), final written medical clearance is required by one of the licensed health care professionals identified above for the athlete to fully return to unrestricted participation in practices and competitions.
 
I have read and understand this document the “Student and Parent Concussion Informed Consent Form” and understand the severities associated with concussions and the need for immediate treatment of such injuries.



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