Approved to begin Return to Learn and/or Return to Play. Approved to only return to class, NOT athletic competition

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Shavonne Ryan
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1 Buffalo Tri-City CUSD #1 Concussion Form Information This form is to be filled out by the head coach, assistant coach, AD, or district administrator that is in charge at the time of the incident. The parent and Athletic Director must be notified. This form must be taken with the student to see an approved medical professional. Students Name: Date of Incident: Location of Incident: Type of Activity: Describe Incident: Name of Medical Professional: Date of Visit to Medical Professional: Student seen is: Approved to begin Return to Learn and/or Return to Play Approved to only return to class, NOT athletic competition Not approved at this time to return to class or athletic competition Reason: Further Instructions: Signature of Medical Professional: Please return this form to the Athletic Director or building administration.

2 Concussion Protocol Return to Play Progression Form Head Injury/ Concussion Management: Step by Step Progression Athlete Name: Current Sport: Evaluation Date: Date to begin Progression: The athlete has been evaluated and deemed safe to begin functional progression back to a sport. Athlete may begin Step 1 on the date outlined above. Athlete should remain at a level of activity as listed provided no symptoms return. If symptoms return, discontinue activity immediately. Stage must be repeated after 24 hours of no symptoms. Length of Activity Stage 1: Light Activity Begin with light aerobic exercise only to increase an athlete s heart rate to15 minutes on an exercise bike, walking, or light jogging, stretching with team, balance training - No weight lifting at this point. Date to Begin Stage 2: Moderate Activity Continue with activities to increase an athlete s heart rate with body or head movement. This includes moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (less time and/or less weight from their typical routine).. - Jog one mile, - Exercise bike (20 Minutes) Stage 3: Heavy Non-Contact Activity (15-20 minutes) Add heavy non-contact physical activity, such as sprinting/running, high-intensity stationary biking, regular weightlifting routine, forward and backward running, carioca, defensive slides, sit-ups, push-ups and burpees. Stage 4: Sports Performance Training (full contact) The athlete may return to practice in a controlled environment with no physical contact. The athlete can participate in non-contact drills and exercises. Stage 5: Return to full game play The athlete may return to practice and full contact/drills appropriate for the sport in practice/games. There are no restrictions. *Once an athlete has completed the above stages fully without return of symptoms, he/she is considered clear to return to full competition. COT Signature: Date: Parent Signature: Athlete: Date:

3 Concussion Definition and Symptoms A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a ding or a bump on the head can be serious. You can t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away. Symptoms may include one or more of the following: Headaches Pressure in head Nausea or vomiting Neck pain Balance problems or dizziness Blurred, double, or fuzzy vision Sensitivity to light or noise Feeling sluggish or slowed down Feeling foggy or groggy Drowsiness Change in sleep patterns Amnesia Don t feel right Fatigue or low energy Sadness Nervousness or anxiety Irritability More emotional Confusion Concentration or memory problems Repeating the same question/comment Signs observed by teammates, parents and coaches include: Appears dazed Vacant facial expression Confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily or displays in coordination Answers questions slowly Slurred speech Shows behavior or personality changes Can t recall events prior to hit Can t recall events after hit Seizures or convulsions Any change in typical behavior or personality Loses consciousness

4 Concussion Protocol 1) Any athlete that exhibits signs, symptoms or behaviors consistent with a concussion will not return to play until cleared by an appropriate health care professional. 2) Athletes showing signs of a concussion will be administered sideline concussion checklist test to determine athletes condition. The test will be administered by the coach, assistant coach, athletic director, district administrator or athletic trainer. 3) If it is confirmed by the team physician or athletic trainer that the student did not sustain a concussion, the head coach may so advise the officials during an appropriate stoppage of play that the athlete may re-enter competition pursuant to the contest rules. If the team physician or athletic trainer are not in attendance, the player may not return to competition that day. 4) In cases where an athlete was not cleared to return to play the same day as he/she was removed from a contest/practice following a possible injury, the athlete shall not return to play or practice until the athlete has been evaluated by and receives written clearance from a licensed physician to begin Tri- City s return to play protocol. - For the purpose of this policy, licensed health care providers consist of physicians licensed to practice medicine in all its branches in Illinois and certified/licensed trainers working in conjunction with physicians licensed to practice medicine in all of it branches in Illinois. 5) Upon visiting a licensed physician, athletes must have a completed (by coach, AD or district Administrator) Tri-City Concussion Information Form regarding the accident which caused the injury. The form is to be completed by the licensed physician and returned to the Athletic Director or district administrator. All athletes suspected of sustaining a concussion must go through the Return to Play protocol. Even if the head injury is not diagnosed as a concussion, athletes still have to go through the Return to Play protocol. 6) It will be the responsibility of the coach or assistant coach to notify student athletes parents (if not present at the game) and the Athletic Director. The Athletic Director will notify district nurse, administration, COT members and the IHSA/IESA as needed.

5 Cognitive Rest A concussion can interfere with school, work, sleep, and social interactions. Many athletes who have a concussion will have difficulty in school with short and long term memory, concentration, and organization. These physical problems typically last no longer than 2-3 weeks, but some of these difficulties may last for months. It is best to lesson the student class load early on after the injury. Most students with concussions recovery fully from the injury. However, returning to school, sports and other regular activities too quickly can prolong the recovery. Return to Learn *In some cases, due to the severity of the injury, returning to school too soon can be difficult for athletes. The steps listed below can be used in such cases. RECOVERY STAGE 1 Complete Physical and Cognitive Rest until Medical Clearance - No School Attendance - Strict Limits on Technology Usage - REST -Symptom Free for 24 Hours? Yes: Begin Stage 2 No: Continue Resting RECOVERY STAGE 2 Return to School with Academic Accommodations - Continue Limits on Technology Usage - Avoid Heavy Backpacks - No Tests, PE, Band or Chorus - Monitor Symptoms - REST when at home -Symptom Free for Next 24 hours? Yes: Begin Stage 3 No: Rest Further until Symptom Free RECOVERY STAGE 3 Continue Academic Accommodations - Attend School Full Time if Possible - Increase Work Load Gradually (testing, homework, etc) - Monitor Symptoms - Incorporate light aerobic activity - REST when at home -Symptom Free for Next 24 hours? Yes: Begin Stage 4 No: Rest Further until Symptom Free RECOVERY STAGE 4 Full Recovery to Academics - Attend School Full Time - Self-Advocate at School (meet due dates, etc) - Resume Normal Activities - Resume Sports following Graduated Return to Play - Stage 4 until Symptom Free ** Symptom-Free means NO lingering Headaches, Sensitivity to Light/Noise, Fogginess, Drowsiness, etc

6 Return to Play After suffering a concussion, no athlete should return to play or practice on the same day. Once an athlete no longer has signs, symptoms, or behaviors of a concussion and is cleared to return to play by an appropriate health care professional, ho or she should proceed in a step wise fashion to allow the brain to re-adjust to exercise. In most cases, the athlete will progress on step each day. The return to play activity program schedule may proceed as below, following medical clearance. Stage 1: Light Activity Begin with light aerobic exercise only to increase an athlete s heart rate to15 minutes on an exercise bike, walking, or light jogging, stretching with team, balance training - No weight lifting at this point Stage 2: Moderate Activity Continue with activities to increase an athlete s heart rate with body or head movement. This includes moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (less time and/or less weight from their typical routine).. - Jog one mile or exercise bike (20 Minutes) Stage 3: Heavy Non-Contact Activity Add heavy non-contact physical activity, such as sprinting/running, high-intensity stationary biking, regular weightlifting routine, forward and backward running, carioca, defensive slides, sit-ups, push-ups and burpees. Stage 4: Sports Performance Training (full contact) The athlete may return to practice in a controlled environment with no physical contact. The athlete can participate in non-contact drills and exercises. Stage 5: Return to full game play The athlete may return to practice and full contact/drills appropriate for the sport in practice/games. There are no restrictions. Concussion Oversight Teams (COT). The COT s primary function will be to develop return-to-play and return-to-learn protocols for students believed to have experienced a concussion. The protocols should be based on peer-reviewed scientific evidence consistent with guidelines from the Center for Disease Control and Prevention. These teams can contain a range of individuals based on the resources available to the school in their community or neighborhood but must include one person who is responsible for implementing and complying with the return-to-play and return-to-learn protocols. Tri-City (COT) Jill Larson Tri-City Superintendent Kara Cummins Tri-City Elementary Principal Stan Price Athletic Director Pete Stoll Athletic Trainer Christy Kindel Tri-City HS Principal Kathy Getz School Nurse Sara Heberling Guidance Counselor Jill Larson and Stan Price will be responsible for implementing and complying with the return to learn and return to play protocols at Tri-City CUSD #1. *Additional members may be added *No later than September 1, 2016, all interscholastic coaches and licensed officials will need to complete a training program of at least two hours on concussions. Coaches, nurses, and game officials must provide the school or district with proof of successful completion of the training. Training must be completed every two years. Head coaches and assistant coaches must complete the required training as well as members of a school/district s COT.

Concussion Information Sheet

Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force