GREEN BROOK MIDDLE SCHOOL
PRE-CONCUSSION TESTING PROGRAM: IMPACT
Dear Parent or Guardian,
The incidence of sports-related concussion in school athletics has increased dramatically over the last decade. Head
trauma or upper torso trauma can lead to serious or even life-threatening situations if not managed correctly. The
CDC Head’s Up campaign has focused on the prevention, diagnosis and management of concussions in students.
The New Jersey Legislature has enacted concussion legislation to achieve early diagnosis and management of
students with suspected head trauma.
Great strides in the prevention, diagnosis and management of concussions have been made in recent years. We want
to make sure that the most advanced strategies are being implemented for Green Brook Middle School athletes.
Therefore, Green Brook Middle School is fostering this health care initiative by providing to its students and parents
information on the effects of head trauma on a student’s developing brain. To further this initiative, the middle school
is currently offering all students, who anticipate being on a Green Brook interscholastic sports team, the opportunity
to take part in an innovative concussion baseline testing program for student athletes. This program will assist the
health care provider in treating a child who sustains head trauma.
The concussion baseline program is called IMPACT which stands for Immediate Post Concussion Assessment and
Cognitive Testing. The IMPACT test is a computerized program, which tests a student’s memory, reaction time,
speed and concentration. It is not an intelligence test. It is a non-invasive “video-game” formatted test that takes
about 20-25 minutes to complete and poses no risk to the student. The IMPACT baseline data is stored with the
student health records and retrieved if head trauma occurs.
If a student is believed to have sustained head or upper body trauma, the pre-trauma IMPACT baseline data will be
given to the student’s parent, or, if requested, to the student’s health care provider. This baseline data will assist the
health care provider in evaluating the extent of the trauma, managing care and limiting potential brain damage that
can occur with head trauma(s). Further IMPACT testing by the health care provider will assist the practitioner in
determining health care and school accommodations needed for the recovery of the student. The IMPACT test is
utilized by the local concussion centers at Morristown Memorial Hospital, Overlook Medical Center, Somerset
Medical Center, St Clares Hospital, St Barnabas Medical Center and the Goryeb Children’s Hospital.
The IMPACT program was obtained through a grant awarded to the middle school nurse through the P.A.C.E.
(Protect Athletes through Concussion Education) Program from Dick’s Sporting Goods. The Green Brook Township
School District is committed to keeping your child’s health and safety at the forefront of his/her athletic experience.
Return this signed form with the sports physical forms.
PERMISSION OR EXCLUSION FROM IMPACT PRE-CONCUSSION TESTING PROGRAM
 I DO NOT wish to have my child complete the IMPACT baseline concussion test. I understand that no baseline
data will be available for my child‘s health care provider to utilize if my child should sustain head trauma. I
indemnify and hold harmless the Green Brook Township School District and its employees and release them from
any liability and responsibility for any adverse affects due to lack of IMPACT baseline data for health evaluation.
 I DO wish to have my child complete the IMPACT baseline concussion test. I understand that if my child is
selected for the “sports team” testing will be done during the sport season. IMPACT baseline data can be made
available to my child‘s health care provider if my child should sustain head trauma. I indemnify and hold harmless
the Green Brook Township School District and its employees and release them from any liability or responsibility for
any adverse effects due to IMPACT baseline data testing or lack thereof.
Parent Signature:
Date:
Student’s Name:
Grade:
7-11-12
Homeroom Teacher: