Sports-Related Concussion and Head Injury Fact Sheet and
Parent/Guardian Acknowledgement Form
A concussion is a brain injury that can be caused by a blow to the head or body that disrupts
normal functioning of the brain. Concussions are a type of Traumatic Brain Injury (TBI), which
can range from mild to severe and can disrupt the way the brain normally functions. Concussions
can cause significant and sustained neuropsychological impairment affecting problem solving,
planning, memory, attention, concentration, and behavior.
The Centers for Disease Control and Prevention estimates that 300,000 concussions are sustained
during sports related activities nationwide, and more than 62,000 concussions are sustained each
year in high school contact sports. Second-impact syndrome occurs when a person sustains a
second concussion while still experiencing symptoms of a previous concussion. It can lead to
severe impairment and even death of the victim.
Legislation (P.L. 2010, Chapter 94) signed on December 7, 2010, mandated measures to be taken
in order to ensure the safety of K-12 student-athletes involved in interscholastic sports in New
Jersey. It is imperative that athletes, coaches, and parent/guardians are educated about the nature
and treatment of sports related concussions and other head injuries. The legislation states that:
• All Coaches, Athletic Trainers, School Nurses, and School/Team Physicians shall
complete an Interscholastic Head Injury Safety Training Program by the 2011-2012
school year.
• All school districts, charter, and non-public schools that participate in interscholastic
sports will distribute annually this educational fact to all student athletes and obtain a
signed acknowledgement from each parent/guardian and student-athlete.
• Each school district, charter, and non-public school shall develop a written policy
describing the prevention and treatment of sports-related concussion and other head
injuries sustained by interscholastic student-athletes.
• Any student-athlete who participates in an interscholastic sports program and is
suspected of sustaining a concussion will be immediately removed from competition or
practice. The student-athlete will not be allowed to return to competition or practice until
he/she has written clearance from a physician trained in concussion treatment and has
completed his/her district’s graduated return-to-play protocol.
Quick Facts
• Most concussions do not involve loss of consciousness
• You can sustain a concussion even if you do not hit your head
• A blow elsewhere on the body can transmit an “impulsive” force to the brain and cause a
concussion
Signs of Concussions (Observed by Coach, Athletic Trainer, Parent/Guardian)
• Appears dazed or stunned
• Forgets plays or demonstrates short term memory difficulties (e.g. unsure of game, opponent)
• Exhibits difficulties with balance, coordination, concentration, and attention
• Answers questions slowly or inaccurately
• Demonstrates behavior or personality changes
• Is unable to recall events prior to or after the hit or fall
Symptoms of Concussion (Reported by Student-Athlete)
• Headache
• Nausea/vomiting
• Balance problems or dizziness
• Double vision or changes in vision
• Sensitivity to light/sound
• Feeling of sluggishness or fogginess
• Difficulty with concentration, short term memory, and/or confusion
What Should a Student-Athlete do if they think they have a concussion?
• Don’t hide it. Tell your Athletic Trainer, Coach, School Nurse, or Parent/Guardian.
• Report it. Don’t return to competition or practice with symptoms of a concussion or head
injury. The sooner you report it, the sooner you may return-to-play.
• Take time to recover. If you have a concussion your brain needs time to heal. While your
brain is healing you are much more likely to sustain a second concussion. Repeat concussions
can cause permanent brain injury.
What can happen if a student-athlete continues to play with a concussion or returns to play
to soon?
• Continuing to play with the signs and symptoms of a concussion leaves the student-athlete
vulnerable to second impact syndrome.
• Second impact syndrome is when a student-athlete sustains a second concussion while still
having symptoms from a previous concussion or head injury.
• Second impact syndrome can lead to severe impairment and even death in extreme cases.
Should there be any temporary academic accommodations made for Student-Athletes who
have suffered a concussion?
• To recover cognitive rest is just as important as physical rest. Reading, texting, testing-even
watching movies can slow down a student-athletes recovery.
• Stay home from school with minimal mental and social stimulation until all symptoms have
resolved.
• Students may need to take rest breaks, spend fewer hours at school, be given extra time to
complete assignments, as well as being offered other instructional strategies and classroom
accommodations.
Student-Athletes who have sustained a concussion should complete a graduated return-toplay before they may resume competition or practice, according to the following protocol:
• Step 1: Completion of a full day of normal cognitive activities (school day, studying for tests,
watching practice, interacting with peers) without reemergence of any signs or symptoms. If no
return of symptoms, next day advance.
• Step 2: Light Aerobic exercise, which includes walking, swimming, and stationary cycling,
keeping the intensity below 70% maximum heart rate. No resistance training. The objective of
this step is increased heart rate.
• Step 3: Sport-specific exercise including skating, and/or running: no head impact activities.
The objective of this step is to add movement.
• Step 4: Non contact training drills (e.g. passing drills). Student-athlete may initiate resistance
training.
• Step 5: Following medical clearance (consultation between school health care personnel and
student-athlete’s physician), participation in normal training activities. The objective of this step
is to restore confidence and assess functional skills by coaching and medical staff.
• Step 6: Return to play involving normal exertion or game activity.
For further information on Sports-Related Concussions and other Head Injuries, please visit:
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www.cdc.gov/concussion/sports/index.html www.nfhs.com
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www.ncaa.org/health-safety www.bianj.org www.atsnj.org
_______________________________ _________________________________ __________
Signature of Student-Athlete
Print Student-Athlete’s Name
Date
_______________________________ _________________________________ __________
Signature of Parent/Guardian
Print Parent/Guardian’s Name
Date
Prevention and Treatment of Sports-Related Concussions and Head Injuries
Prevention
1. Pre-season student baseline testing.
2. Review of educational information for student-athletes on prevention of concussions.
3. All Coaches, School Nurses, School/Team Physicians and Licensed Athletic Trainers
complete an Interscholastic Head Injury Training Program, “Concussion in Sports”
hosted by the National Federation of State High Schools Association.
4. Reinforcement of the importance of early identification and treatment of concussions to
improve recovery.
• Student-athletes who are exhibiting the signs or symptoms of a sports-related
concussion or other head injuries during practice or competition shall be immediately removed
from play and may not return to play that day.
Possible Signs of Concussion:
(Could be observed by Coaches, Licensed Athletic Trainer, School/Team Physician, School
Nurse)
1. Appears dazed, stunned, or disoriented.
2. Forgets plays, or demonstrates short term memory difficulty.
3. Exhibits difficulties with balance or coordination.
4. Answers questions slowly or inaccurately.
5. Loses consciousness.
Possible Symptoms of Concussion
(Reported by the student athlete to Coaches, Licensed Athletic Trainer, School/ Team Physician,
School Nurse, Parent/ Guardian)
1. Headache
2. Nausea/Vomiting
3. Balance problems or dizziness.
4. Double vision or changes in vision.
5. Sensitivity to light or sound/noise.
6. Feeling sluggish or foggy.
7. Difficulty with concentration and short term memory.
8. Sleep disturbance.
9. Irritability
• Student-Athletes must be evaluated by a physician or licensed health care provider
trained in the evaluation and management of concussion to determine the presence or absence of
a sports-related concussion or head injuries.
• To return to practice and competition the student-athlete must follow the protocol:
1. Immediate removal from competition or practice. 911 should be called if there is a
deterioration of symptoms, loss of consciousness, or direct neck pain associated with the
injury.
2. When available the student-athlete should be evaluated by the school’s licensed
healthcare provider who is trained in the evaluation and management of concussions.
3. School personnel (Athletic Director/Building Administrator, Licensed Athletic Trainer,
School Nurse, Coach, etc.) should make contact with the student-athlete’s
parent/guardian and inform him/her of the suspected sports-related concussion or head
injury.
4. School personnel (Athletic Director/ Building Administrator, Licensed Athletic Trainer,
School Nurse, Coach, etc.) shall provide the student-athlete with district board of
education approved suggestions for management/ medical checklist to provide their
parent/guardian and physician or other licensed healthcare professional trained in the
evaluation and management of sports related concussions and other head injuries (See
attachment sections at end of model policy for examples CDC, NCAA, etc.)
5. The student-athlete must receive written clearance from a physician, trained in the
evaluation and management of concussions that states the student-athlete is asymptomatic
at rest and may begin the local districts’ graduated return-to-play protocol. Medical
clearance that is inconsistent with district, charter, and non-public school policy may not
be accepted and such matters will be referred to the school/team physician.
Graduated Return to Competition and Practice Protocol
• Complete physical, cognitive, emotional, and social rest is advised while the studentathlete is experiencing symptoms and signs of a sports-related concussion or other head injury.
(Minimize mental exertion, limiting overstimulation, multi-tasking etc.)
• After written medical clearance is given by a physician trained in the evaluation and
management of concussions stating that the student-athlete is asymptomatic at rest, the studentathlete may begin a graduated individualized return-to-play protocol supervised by a licensed
athletic trainer, school/team physician or in cases where the afore mentioned are not available a
physician or licensed health care provider trained in the evaluation and management of sportsrelated concussions. The following steps should be followed:
1. Completion of a full day of normal cognitive activities (school day, studying for tests,
watching practice, interacting with peers) without re-emergence of any signs or
symptoms. If no return of symptoms, next day advance to:
2. Light aerobic exercise, which includes walking, swimming, or stationary cycling, keeping
the intensity < 70% maximum percentage heart rate: no resistance training. The objective
of this step is increased heart rate. If no return of symptoms, next day advance to:
3. Sport-specific exercise including skating, and/or running; no head impact activities. The
objective of this step is to add movement and continue to increase heart rate. If no return
of symptoms, next day advance to:
4. Non-contact training drills (e.g., passing drills). The student-athlete may initiate
progressive resistance training. If no return of symptoms, next day advance to:
5. Following medical clearance (consultation between school health care personnel, i.e.,
Licensed Athletic Trainer, School/Team Physician, School Nurse and student-athlete’s
physician), participation in normal training activities. The objective of this step is to
restore confidence and to assess functional skills by the coaching staff. If no return of
symptoms, next day advance to:
6. Return to play involving normal exertion or game activity.
• In the absence of daily testing by knowledgeable school district staff (i.e. Licensed Athletic
Trainer, School/Team Physician) to clear a student-athlete to begin the graduated return-to-play
protocol a student –athlete should observe a 7 day rest/recovery period before commencing the
protocol. Younger students (K-8) should observe the 7 day rest/recovery period (after they are
symptom free at rest) prior to initiating the graduated-return-to play protocol. A physician trained
in the evaluation and management of concussion as well as the parents/guardians of the studentathlete shall monitor the student-athlete in the absence of knowledgeable school district staff
(i.e., Athletic Trainer, School/Team Physician). School Nurses may serve as an advocate for
student-athletes in communicating signs and symptoms to physicians and parents/guardians.
• Utilization of available tools such as symptom checklists, baseline and balance testing
are suggested.
• If the student athlete exhibits a re-emergence of any concussion signs or symptoms once
they return to physical activity, he/she will be removed from further exertional activities and
returned to his/her school/team physician or primary care physician.
• If concussion symptoms reoccur during the graduated return-to-play protocol, the
student-athlete will return to the previous level of activity that caused no symptoms.
Temporary Accommodations for Student-Athletes with Sports-Related Head Injuries
• Rest is the best “medicine” for healing concussions or other head injuries. The
concussed brain is affected in many functional aspects as a result of the injury. Memory,
attention span, concentration and speed of processing significantly impacts learning. Further,
exposing the concussed student-athlete to the stimulating school environment may delay the
resolution of symptoms needed for recovery.
• Accordingly, consideration of the cognitive effects in returning to the classroom is also
an important part of the treatment of sports-related concussions and head injuries.
• Mental exertion increases the symptoms from concussions and affects recovery. To
recover, cognitive rest is just as important as physical rest. Reading, studying, computer usage,
testing, texting – even watching movies if a student is sensitive to light/sound – can slow a
student's recovery. In accordance with the Centers for Disease Control's toolkit on managing
concussions boards of education may look to address the student’s cognitive needs in the
following ways.
• Students who return to school after a concussion may need to:
1. Take rest breaks as needed.
2. Spend fewer hours at school.
3. Be given more time to take tests or complete assignments. (All courses should be
considered)
4. Receive help with schoolwork.
5. Reduce time spent on the computer, reading, and writing.
6. Be granted early dismissal to avoid crowded hallways.
Name________________________________ Date _______________________________
Symptom Checklist: Circle “YES” if you have experienced the symptom within the last 24
hours or “NO” if you have not experienced the symptom over the last 24 hours.
1. Have you had a headache in the last 24 hours?
2. Have you experience nausea in the last 24 hours?
3. Have you had any difficulty balancing in the last 24 hours?
4. Have you experienced fatigue in the last 24 hours?
5. Have you experienced drowsiness in the last 24 hours?
6. Have you experienced sleep disturbances in the last 24 hours?
7. Have you had difficulty concentrating in the last 24 hours?
8. In the last 24 hours have you felt like you are “in a fog”?
9. In the last 24 hours have you felt “slowed down”?
10. Have your eyes been sensitive to light in the last 24 hours?
11. Have you felt sadness in the last 24 hours?
12. Have you experienced vomiting in the last 24 hours?
13. Have your ears been sensitive to noise in the last 24 hours?
14. Have you experienced nervousness in the last 24 hours?
15. Have you had difficulty remembering things in the last 24 hours?
16. Have you experienced numbness in the last 24 hours?
17. Have you experienced any tingling sensations in the last 24 hours?
18. Have you experienced dizziness in the last 24 hours?
19. Have you experienced any neck pain in the last 24 hours?
20. Have you been irritable in the last 24 hours?
21. Have you experienced feelings of depression in the last 24 hours?
22. Have you experienced blurred vision in the last 24 hours?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Duration
Briefly
1) Headache
2) Nausea
3) Difficulty
balancing
4) Fatigue
5) Drowsiness
6) Sleep
Disturbances
7) Difficulty
Concentrating
8) Feeling in a fog
9) Feeling slowed
down
10) Sensitive to
Light
11) Sadness
12) Vomiting
13) Sensitive to
Noise
14) Nervousness
15) Difficulty
Remembering
16) Numbness
17) Tingling
18) Dizziness
19) Neck Pain
20) Irritable
21) Depression
22) Blurred
Vision
Sometimes
Severity
Always
Very Low---------------Very High
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ImPACT
In recent years, medical science has increasingly confirmed the potential, long-term effects of
repeated, untreated head injuries among athletes. Because of this, we have been pro-active and
aggressive in taking measures to assess the severity of concussions and promote a safe return to
play.
We have now implemented a software program to assess head injuries, called ImPACT. This
program tests all athletes pre-season and obtains a baseline measurement of neurocognitive
function. During the season, if an athlete has a suspected head injury, he/she is retested and the
result is compared to that original, baseline measurement. An athlete is not allowed to return to
play after a head injury until his/her measurement return to the baseline “normal” status.
The ImPACT software has been successfully used in college and professional athletics to help
protect athletes and support their safe return to play and we are committed to using the same
software to protect the health and safety of our students.
We hope that the following FAQs will provide the answers to any questions you may have about
ImPACT:
What is ImPACT?
ImPACT (Immediate Post Concussion Assessment and Cognitive Testing), is a software tool
which was developed by the University of Pittsburgh Medical Center (UPMC). ImPACT is used
in many professional, collegiate and high school sports programs across the country, to
successfully diagnose and manage concussions. If an athlete is believed to have suffered a head
injury, ImPACT is used to help determine its severity and help monitor the healing process.
How does ImPACT work?
During pre-season, before any physical contact is sustained, an athlete takes a 30-minute
computerized test that measures brain processing, speed, memory and visual motor skills. The
ImPACT testing procedures are non-invasive and pose no risks to your son/daughter. The results
are collected and stored by our athletic trainers and physician. If an athlete experiences a head
injury or concussion during the season, he/she is re-tested and the result is compared to the
preseason baseline data. Doing this allows physicians to determine the athlete’s neuro-cognitive
status and determine when it is safe for the player to return to active sports.
How is the ImPACT date used?
If an injury of this nature occurs to your son or daughter, you will be promptly contacted with all
the details. The pre-season and post-injury test data may be sent to a neuropsychologist or
neurosurgeon at the University of Pittsburgh Medical Center (UPMC) to help evaluate the injury.
The information can also be shared with an athlete’s physician. The test data will enable these
health professionals to determine when return-to-play is appropriate and safe for an injured
athlete.
Which Athletes Must Complete ImPACT?
Athletes who plan to participate in any of the contact sports must complete the ImPACT baseline
evaluation on-line, prior to the start of season.
How Does an Athlete Take the ImPACT Test?
The test is an on-line baseline test. See the following page for instructions for online testing.
Impact Testing Instructions
DO NOT TAKE THIS TEST IF:
-
You have taken the test within the past 2 years
You currently have a head injury
To ensure a valid test, please follow these instructions. It is very important that you are able
to fully concentrate during the entire test. Poor performance will result in an invalid test and
will require a retake!
• Set aside 30 minutes in a quiet room with no distractions to take the test.
• No headphones or cell phone use during the test. Turn off any televisions, radio or anything
else that can produce background noise.
• Tell siblings and family members about the importance of the test to avoid interruptions or
distractions.
• Note the test will begin by asking you background questions called the “demographic” section.
• There are 6 test sections called “modules.” These include word memory, design memory, Xs
and Os,
symbol match, color word match and three letters.
• Take your time to read each section’s instructions very carefully. Each module is self
explanatory.
• It is common to perform the color word match module incorrectly, please read that section’s
instructions thoroughly.
• Other than the initial demographic section, do not ask anyone to help you with your
performance during the
test, such as assistance with memory questions, etc. Do not write anything down during the test
to aid memory.
You must use a standard external mouse. You may not use a finger mouse pad (ie: laptop
mouse), a Track
Mouse, or anything other than a standard mouse.
1. To take the baseline test, go to: www.impacttestonline.com/schools, select “NJ” and then click
on “Launch Baseline Test.”
2. Make certain to select “Dwight Morrow High School” when asked for “school/organization”
in the demographic section.
3. Your test results are not displayed once you are finished (all results are password protected).
4. Please note our test contract with Impact does not allow for unlimited baseline tests. Please do
not allow others to take an additional test.
5. If you do not have access to the internet or a home computer that meets the above
requirements, contact the Athletic Trainer to arrange a testing time at school.
Thank you for participating in our Impact Concussion Management Program.