Yoakum Independent School District. Concussion Policy & Procedures Handbook

Transcription

1 Yoakum Idepedet School District Cocussio Policy & Procedures Hadbook

2 CONCUSSION OVERSIGHT TEAM Medical Adviser James Drost, MD 210 Nelso St, Suite C Yoakum, Texas Chair Carrie Frak, L.A.T., EMT P.O. Box 737 Yoakum, Texas Carol Bade, FNP, RN 210 Nelso St. Suite C Yoakum, Texas William Moehlma, MD 210 Nelso St. Yoakum, Texas

3 LEGISLATION

4 Texas HB 2038, Tasha s Cocussio Law, Talkig Poits: The bill defies who the Licesed Health Care Professioals are that will participate i the developmet ad implemetatio of the cocussio oversight team i schools. The studet ad the studet s paret or guardia or aother perso with legal authority to make medical decisios for the studet: have siged a form for that school year that ackowledges receivig ad readig writte iformatio that explais cocussio prevetio, symptoms, treatmet, ad oversight ad that icludes guidelies for safety resumig participatio i a athletic activity followig a cocussio. The form must be approved by the Uiversity Iterscholastic League. The bill will madate a Cocussio Oversight Team chose by each school district or charter school, headed by at least oe physicia with cocussio maagemet traiig. The bill requires studets who are suspected of havig sustaied a cocussio must be removed from the activity immediately. The studet suspected of sustaiig a cocussio must be evaluated by a physicia of his/her choosig. The school district shall verify the studet has successfully completed each requiremet of the retur-to-play protocol ecessary for the studet to retur to play established by the cocussio oversight team. The treatig physicia shall sig a writte statemet idicatig that, i their professioal judgmet, it is safe for the studet to retur to play. The studet ad the studet s paret or guardia or aother perso with legal authority to make medical decisios for the studet ackowledges i writig: He/she have bee iformed cocerig ad cosets to the studet s participatio i returig to play i accordace with the retur-to-play protocol; He/she uderstad the risks associated with the studet returig to play ad will comply with ay ogoig requiremets i the retur-to-play protocol; He/she cosets to the disclosure to appropriate persos, cosistet with the Health Isurace Portability ad Accoutability Act of 1996 (Pub. L. No ), of the treatig physicia s writte statemet regardig the retur-to-play recommedatios of the treatig physicia; He/she uderstad the immuity provisios icluded i the bill. 1

5 If the school district or charter school employs a athletic traier, he/she is resposible for the compliace of the athlete with the retur-to-play protocol. A coach of a iterscholastic athletics team may ot authorize a studet s retur to play. The school district superitedet or the superitedet s desigee or, i the case of a home-rule school district or ope-erollmet charter school, the perso who serves the fuctio of superitedet or that perso s desigee shall supervise a athletic traier or other perso resposible for compliace with the retur-to-play protocol. The perso who has supervisory resposibilities may ot be a coach of a iterscholastic athletics team. The bill establishes a educatio course for coaches. Cotiuig educatio requiremets i cocussio maagemet for athletic traiers which ca be met i the two year cycle. It is recommeded that physicias take cotiuig educatio i cocussio maagemet, whe servig o the cocussio oversight team. The bill provides for immuity from liability for school districts or members of the cocussio oversight team complyig with this act. The bill will allow the Commissioer of Educatio to develop rules to implemet the bill. There should be o fiscal impact i the ext bieium attached to the implemetatio of the bill. 2

6 Texas HB 2038 AN ACT relatig to prevetio, treatmet, ad oversight of cocussios affectig public school studets participatig i iterscholastic athletics. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTIONA1.AAThis Act may be cited as Natasha s Law i hoor of Natasha Helmick for her courage i advocatig for the eactmet of this Act ad i hoor of all other studet athletes at the middle ad high school levels. SECTIONA2.AAChapter 38, Educatio Code, is ameded by addig Subchapter D to read as follows: SUBCHAPTER D. PREVENTION, TREATMENT, AND OVERSIGHT OF CONCUSSIONS AFFECTING STUDENT ATHLETES Sec.A AADEFINITIONS. I this subchapter: (1)AA"Advaced practice urse" has the meaig assiged by Sectio , Occupatios Code. (2)AA"Athletic traier" has the meaig assiged by Sectio , Occupatios Code. (3)AA"Coach" icludes a assistat coach. (4)AA"Cocussio" meas a complex pathophysiological process affectig the brai caused by a traumatic physical force or impact to the head or body, which may: (A)AAiclude temporary or prologed altered brai fuctio resultig i physical, cogitive, or emotioal symptoms or 1

7 Texas HB 2038 altered sleep patters; ad (B)AAivolve loss of cosciousess. (5)AA"Licesed health care professioal" meas a advaced practice urse, athletic traier, europsychologist, or physicia assistat, as those terms are defied by this sectio. (6)AA"Neuropsychologist" meas a perso who: (A)AAholds a licese to egage i the practice of psychology issued uder Sectio , Occupatios Code; ad (B)AAspecializes i the practice of europsychology. (7)AA"Ope-erollmet charter school" icludes a school grated a charter uder Subchapter E, Chapter 12. (8)AA"Physicia" meas a perso who holds a licese to practice medicie i this state. (9)AA"Physicia assistat" meas a perso who holds a licese issued uder Chapter 204, Occupatios Code. Sec.A AAAPPLICABILITY. This subchapter applies to a iterscholastic athletic activity, icludig practice ad competitio, sposored or sactioed by: (1)AAa school district, icludig a home-rule school district, or a public school, icludig ay school for which a charter has bee grated uder Chapter 12; or (2)AAthe Uiversity Iterscholastic League. Sec.A AAOVERSIGHT OF CONCUSSIONS BY SCHOOL DISTRICTS AND CHARTER SCHOOLS; RETURN-TO-PLAY PROTOCOL DEVELOPMENT BY CONCUSSION OVERSIGHT TEAM. (a) The goverig body of each school district ad ope-erollmet charter school with studets erolled 2

8 Texas HB 2038 who participate i a iterscholastic athletic activity shall appoit or approve a cocussio oversight team. (b)aaeach cocussio oversight team shall establish a retur-to-play protocol, based o peer-reviewed scietific evidece, for a studet s retur to iterscholastic athletics practice or competitio followig the force or impact believed to have caused a cocussio. Sec.A AACONCUSSION OVERSIGHT TEAM: MEMBERSHIP. (a) Each cocussio oversight team must iclude at least oe physicia ad, to the greatest extet practicable, cosiderig factors icludig the populatio of the metropolita statistical area i which the school district or ope-erollmet charter school is located, district or charter school studet erollmet, ad the availability of ad access to licesed health care professioals i the district or charter school area, must also iclude oe or more of the followig: (1)AAa athletic traier; (2)AAa advaced practice urse; (3)AAa europsychologist; or (4)AAa physicia assistat. (b)aaif a school district or ope-erollmet charter school employs a athletic traier, the athletic traier must be a member of the district or charter school cocussio oversight team. (c)aaeach member of the cocussio oversight team must have had traiig i the evaluatio, treatmet, ad oversight of cocussios at the time of appoitmet or approval as a member of the team. 3

9 Texas HB 2038 H.B. Sec.A AAREQUIRED ANNUAL FORM ACKNOWLEDGING CONCUSSION INFORMATION. A studet may ot participate i a iterscholastic athletic activity for a school year util both the studet ad the studet s paret or guardia or aother perso with legal authority to make medical decisios for the studet have siged a form for that school year that ackowledges receivig ad readig writte iformatio that explais cocussio prevetio, symptoms, treatmet, ad oversight ad that icludes guidelies for safely resumig participatio i a athletic activity followig a cocussio. The form must be approved by the Uiversity Iterscholastic League. Sec.A AAREMOVAL FROM PLAY IN PRACTICE OR COMPETITION FOLLOWING CONCUSSION. A studet shall be removed from a iterscholastic athletics practice or competitio immediately if oe of the followig persos believes the studet might have sustaied a cocussio durig the practice or competitio: (1)AAa coach; (2)AAa physicia; (3)AAa licesed health care professioal; or (4)AAthe studet s paret or guardia or aother perso with legal authority to make medical decisios for the studet. Sec.A AARETURN TO PLAY IN PRACTICE OR COMPETITION. (a) A studet removed from a iterscholastic athletics practice or competitio uder Sectio may ot be permitted to practice or compete agai followig the force or impact believed to have caused the cocussio util: (1)AAthe studet has bee evaluated, usig established 4

10 Texas HB 2038 H.B. medical protocols based o peer-reviewed scietific evidece, by a treatig physicia chose by the studet or the studet s paret or guardia or aother perso with legal authority to make medical decisios for the studet; (2)AAthe studet has successfully completed each requiremet of the retur-to-play protocol established uder Sectio ecessary for the studet to retur to play; (3)AAthe treatig physicia has provided a writte statemet idicatig that, i the physicia s professioal judgmet, it is safe for the studet to retur to play; ad (4)AAthe studet ad the studet s paret or guardia or aother perso with legal authority to make medical decisios for the studet: (A)AAhave ackowledged that the studet has completed the requiremets of the retur-to-play protocol ecessary for the studet to retur to play; (B)AAhave provided the treatig physicia s writte statemet uder Subdivisio (3) to the perso resposible for compliace with the retur-to-play protocol uder Subsectio (c) ad the perso who has supervisory resposibilities uder Subsectio (c); ad (C)AAhave siged a coset form idicatig that the perso sigig: (i)aahas bee iformed cocerig ad cosets to the studet participatig i returig to play i accordace with the retur-to-play protocol; (ii)aauderstads the risks associated with 5

11 Texas HB 2038 H.B. the studet returig to play ad will comply with ay ogoig requiremets i the retur-to-play protocol; (iii)aacosets to the disclosure to appropriate persos, cosistet with the Health Isurace Portability ad Accoutability Act of 1996 (Pub. L. No ), of the treatig physicia s writte statemet uder Subdivisio (3) ad, if ay, the retur-to-play recommedatios of the treatig physicia; ad (iv)aauderstads the immuity provisios uder Sectio (b)aaa coach of a iterscholastic athletics team may ot authorize a studet s retur to play. (c)aathe school district superitedet or the superitedet s desigee or, i the case of a home-rule school district or ope-erollmet charter school, the perso who serves the fuctio of superitedet or that perso s desigee shall supervise a athletic traier or other perso resposible for compliace with the retur-to-play protocol. The perso who has supervisory resposibilities uder this subsectio may ot be a coach of a iterscholastic athletics team. Sec.A AATRAINING COURSES. (a) The Uiversity Iterscholastic League shall approve for coaches of iterscholastic athletic activities traiig courses that provide for ot less tha two hours of traiig i the subject matter of cocussios, icludig evaluatio, prevetio, symptoms, risks, ad log-term effects. The league shall maitai a updated list of idividuals ad orgaizatios authorized by the league to provide 6

12 Texas HB 2038 H.B. the traiig. (b)aathe Departmet of State Health Services Advisory Board of Athletic Traiers shall approve for athletic traiers traiig courses i the subject matter of cocussios ad shall maitai a updated list of idividuals ad orgaizatios authorized by the board to provide the traiig. (c)aathe followig persos must take a traiig course i accordace with Subsectio (e) from a authorized traiig provider at least oce every two years: (1)AAa coach of a iterscholastic athletic activity; (2)AAa licesed health care professioal who serves as a member of a cocussio oversight team ad is a employee, represetative, or aget of a school district or ope-erollmet charter school; ad (3)AAa licesed health care professioal who serves o a voluteer basis as a member of a cocussio oversight team for a school district or ope-erollmet charter school. (d)aaa physicia who serves as a member of a cocussio oversight team shall, to the greatest extet practicable, periodically take a appropriate cotiuig medical educatio course i the subject matter of cocussios. (e)aafor purposes of Subsectio (c): (1)AAa coach must take a course described by Subsectio (a); (2)AAa athletic traier must take: (A)AAa course described by Subsectio (b); or (B)AAa course cocerig the subject matter of 7

13 Texas HB 2038 cocussios that has bee approved for cotiuig educatio credit by the appropriate licesig authority for the professio; ad (3)AAa licesed health care professioal, other tha a athletic traier, must take: (A)AAa course described by Subsectio (a) or (b); or (B)AAa course cocerig the subject matter of cocussios that has bee approved for cotiuig educatio credit by the appropriate licesig authority for the professio. (f)aaeach perso described by Subsectio (c) must submit proof of timely completio of a approved course i compliace with Subsectio (e) to the school district superitedet or the superitedet s desigee or, i the case of a home-rule school district or ope-erollmet charter school, a perso who serves the fuctio of a superitedet or that perso s desigee. (g)aaa licesed health care professioal who is ot i compliace with the traiig requiremets uder this sectio may ot serve o a cocussio oversight team i ay capacity. Sec.A AAIMMUNITY. This subchapter does ot: (1)AAwaive ay immuity from liability of a school district or ope-erollmet charter school or of district or charter school officers or employees; (2)AAcreate ay liability for a cause of actio agaist a school district or ope-erollmet charter school or agaist district or charter school officers or employees; (3)AAwaive ay immuity from liability uder Sectio , Civil Practice ad Remedies Code; or 8

14 Texas HB 2038 H.B. (4)AAcreate ay cause of actio or liability for a member of a cocussio oversight team arisig from the ijury or death of a studet participatig i a iterscholastic athletics practice or competitio, based o service or participatio o the cocussio oversight team. Sec.A AARULES. The commissioer may adopt rules as ecessary to admiister this subchapter. SECTIONA3.AASubchapter D, Chapter 38, Educatio Code, as added by this Act, applies begiig with the school year. SECTIONA4.AANotwithstadig Sectio (f), Educatio Code, as added by this Act, a perso required uder Sectio (c), Educatio Code, as added by this Act, to take a traiig course i the subject of cocussios must iitially complete the traiig course ot later tha September 1, SECTIONA5.AAThis Act takes effect immediately if it receives a vote of two-thirds of all the members elected to each house, as provided by Sectio 39, Article III, Texas Costitutio. If this Act does ot receive the vote ecessary for immediate effect, this Act takes effect September 1,

15 Texas HB 2038 AAAAPresidet of the Seate Speaker of the HouseAAAAAA I certify that H.B. No was passed by the House o May 5, 2011, by the followig vote:aayeas 127, Nays 7, 2 preset, ot votig. Chief Clerk of the HouseAAA I certify that H.B. No was passed by the Seate o May 24, 2011, by the followig vote:aayeas 31, Nays 0. Secretary of the SeateAAAA APPROVED:AA AAAAAAAAAAAAAAAAAAAADateAAAAAAAAAA AAAAAAAAAAA AAAAAAAAAAAAAAAAAAGoverorAAAAAAA 10

16 POLICY & PROCEDURES

17 Yoakum Idepedet School District Head Ijury Assessmet, Prevetio, Maagemet, ad Retur to Play Guidelies The followig policy, procedures, ad guidelies o assessmet, prevetio, ad maagemet of head ijuries, as well as retur to play guidelies has bee developed i accordace with Texas Natasha s Law ad the goals of YISD athletics ad Health Services to esure the well-beig of each studet athlete. The risk of repeated cocussios ad secod impact sydrome is also a cocerig factor. These two problems ca have log lastig, ad eve termial effects, o the athlete. Cotiuig to play with the sigs ad symptoms of a cocussio leaves athletes especially vulerable to greater ijury. There is a icreased risk of sigificat damage from aother cocussio before completely recoverig from the first oe. This ca lead to prologed recovery, or eve to severe brai swellig (secod impact sydrome) with devastatig ad eve fatal cosequeces. It is well kow that adolescet or teeage athletes will ofte uder report symptoms of ijuries (Icludig cocussios). As a result, educatio of admiistrators, coaches, parets, ad studets is the key for studet athlete s safety. Purpose The YISD Athletic Departmet recogizes that cocussios pose a sigificat health risk for studet athletes. Therefore, the Athletics Departmet has implemeted policies ad procedures to deal with the assessmet, prevetio, maagemet, ad retur to play guidelies for studet athletes who have sustaied a head ijury. 1

18 Prevetio I a effort to reduce the umber of head ijuries i YISD the district isists that safety comes first. The followig procedures will be used as guidelies to assist i the prevetio of head ijuries. Teach ad practice safe playig techiques Teach athletes the dagers of playig with a cocussio Ecourage athletes to follow the rules of play ad to practice good sportsmaship at all times Make sure athletes wear the right protective equipmet for their activity (such as helmets, paddig, ad mouth guards) All headgear must be NOCSAE certified Make sure the headgear fits the idividual, ad are secured properly to the idividual For all sports that require headgear, a coach or appropriate desigee should check headgear before use to make sure air bladders work ad are appropriately filled. Paddig should be checked to make sure they are i proper workig coditio. Although all head ijuries will ot be preveted, YISD is workig proactively i order to reduce the umber ad severity of head ijuries that do occur. Reportig Head Ijuries It is importat that the studet athlete/ paret report all head ijuries received to the athletic traier. This icludes ay head ijury that occurs out of the school eviromet. It is importat that ay head ijuries be reported before ay physical activity. Athletic Veue Evaluatio I all cases i which a head ijury is suspected the athlete will be removed from athletic participatio ad a iitial assessmet will take place. The athlete will NOT be allowed further participatio o the day of ijury. The iitial assessmet will utilize the YISD Cocussio Maagemet Card. Followig the iitial assessmet further medical evaluatio will be determied as per Tasha s Law. YISD Home Istructios for Head Ijury will be provided, ad parets/guardias will be cotacted. 2

19 Health Care Professioal Evaluatio Evaluatio by Health Care Professioals should iclude a eurological ad a fuctioal test. A eurological test should iclude but is ot limited to eye movemets, pupil respose, balace (static ad dyamic), hearig, ad visio. A fuctioal test should iclude but is ot limited to heal toe walkig, joggig, ad progressive fuctioal activity. School Evaluatio Ay athlete that has sustaied a head ijury is required to report to the high school athletic traier daily. Treatmet/ Rehabilitatio YISD athletes who sustai a head ijury will be istructed to rest, meaig total rest. Physical ad cogitive rest, icludig but ot limited to, NO athletic participatio, NO recreatioal exercise, NO video games/ TV, NO computer usage, ad NO text messagig. Academically, if deemed ecessary teachers will be otified ad academic accommodatios will be made. Follow-up Evaluatio YISD athletes who have sustaied a head ijury will be required to follow the retur to play guidelies. Athletes will be required to check i with their athletic traier daily util cleared by a medical professioal. Oce cleared by a medical professioal parets ad athletes will be required to sig a school cocussio release ad the approved retur to play progressio will begi. Eve if cleared by a physicia, athletes may ot pass the progressive retur to play protocol. 3

20 Head Ijury Data Withi seve days of a head ijury occurrig or beig cleared, all iformatio will be reported to the Cocussio Oversight Team. A stadardized reportig form will be utilized for reportig purposes. The Athletic Traier will report to the Cocussio Oversight Team Chairperso Liability Provisios The studet ad the studet s paret or guardia or aother perso with legal authority to make medical decisios for the studet uderstads this policy does ot: Waive ay immuity from liability of a school district or ope-erollmet charter school or of district or charter school officers or employees Create ay liability for a cause of actio agaist a school district or opeerollmet charter school or agaist district or charter school officers or employees Waive ay immuity from liability uder Sectio , Civil Practice ad Remedies Code Create ay liability for a member of a cocussio oversight team arisig from the ijury or death of a studet participatig i a iterscholastic athletics practice of competitio, based oly o service o the cocussio oversight team. 4

21 YISD Retur to Play Cosideratios YISD Retur to Play Cosideratios Followig a Head Ijury I Yoakum Idepedet School District is proactive i the prevetio, recogitio, ad maagemet of cocussios i order to limit the risk of cocussios associated with athletics. As well as to limit the potetial catastrophic ad log term risks associated with sustaiig a cocussio. Therefore the maagemet ad retur to play decisios will remai i the realm of cliical judgmet o a idividual basis by both the Licesed Athletic Traier ad the Physicia. YISD protocol followig a head ijury follows a stepwise progressio. The athlete should be released from a physicia, have a siged UIL approved retur to play paret/ athlete coset form, ad be symptom free for 24 hours before begiig this progressio. The athlete should complete each level ad progress to the ext (i 24 hour itervals) if they remai asymptomatic both at rest ad with exercise. Should the athlete become symptomatic durig the progressio, they should drop back to the previous asymptomatic level ad try to progress after a 24 hour period of rest has passed. If the athlete remais symptomatic for a exteded period of time the athlete may eed to retur to the physicia. Level 1- Light aerobic exercise- 5 to 10 miutes o a exercise bike or light jog; o weight liftig, resistace traiig, or ay other exercise. Level 2- Moderate aerobic exercise miutes of ruig at moderate itesity i the gym or o the field without a helmet or other equipmet. Level 3- No- cotact traiig drills i full uiform. May begi weight liftig, resistace traiig, ad other exercises. Level 4- Full cotact practice or traiig. Level 5- Full game play. Cotiued post-cocussive symptoms, prior cocussio history ad ay diagostic testig results alog with eurocogitive testig ad physical exam, will be utilized by a Physicia ad athletic traier i establishig a timelie for a athlete s retur to activity. It is importat to ote that this timelie could last over a period of days, weeks, moths, or potetially medically disqualify the studet from athletics. All cases will be hadled o a idividual basis. All cocussios are to be reported to the Oversight Committee Chairperso by the high school athletic traier or middle school coach. The iformatio reported via will iclude the date of cocussio, sport, evet, geder, date of physicia release, date passed progressive retur protocol, ad school ame. A follow-up will also be set to the Oversight Committee Chairperso whe fial retur to play has bee determied by the high school athletic traier, safety coordiator, or school urse. I

22 FORMS

23 YISD Cocussio Maagemet Card YISD Cocussio Maagemet Card Possible Sigs ad Symptoms Evaluatio Sigs Observed by Staff appears to be dazed or stued is cofused about assigmet forgets plays is usure of game, score, or oppoet moves clumsily aswers questios slowly loses cosciousess (eve temporarily) shows behavior or persoality chage forgets evets prior to hit (retrograde) forgets evets after hit (aterograde) Symptoms Reported by Athlete headache ausea balace problems or dizziess double or fuzzy visio sesitivity to light or oise feelig sluggish feelig foggy chage i sleep patter cocetratio or memory problems Symptoms may worse with exertio or become preset over time. Ay failure should be cosidered abormal. I O-Field Cogitive Testig Orietatio Whe did the headache start? What stadium/school is this? Who is the opposig team? What moth is it? What day is it? Aterograde Amesia Ask the athlete to repeat three words. Ex. Girl, Dog, Gree Ex. Ball, Red, School Retrograde Amesia Ask the athlete the followig questios. Do you remember what happeed? Whe was the last time you ate? What did you have to eat last? What quarter/period are we i? What is the score of the game? Cocetratio Ask the athlete to do the followig. Repeat the days of the week backward (startig with today). Repeat series of umbers backward: Ex. 419 (914 is correct) 6385 (5836 is correct) Word List Memory Ask the athlete to repeat the three words from earlier Ex. Girl, Dog, Gree Ex. Ball, Red, School Ay failure should be cosidered abormal. Cosult a physicia followig a suspected cocussio. I

24 YISD Home Istructios YISD Home Istructios for Head Ijury I (athlete ame) received a head ijury, commoly called a cocussio o (date) while participatig i a athletic evet. The followig are istructios for this perso s care over the ext few days. Do ot drive a vehicle Rest, No physical activity Do ot take Aspiri or Ibuprofe (Advil or Motri) Tyleol (Acetamiophe) may be acceptable You may sleep, but should be checked o periodically if exhibitig moderate to severe symptoms Sigs ad symptoms of a closed head ijury do ot always preset util hours or sometimes days after the iitial trauma. Do to this fact; you should be aware of possible sigs ad symptoms that idicate a sigificat head ijury icludig but ot limited to the followig. Persistet or repeated vomitig Covulsios/ seizure Difficulty seeig Ay peculiar movemets of the eyes, or oe pupil is larger tha the other Restless, irritability, or drastic chages i emotioal cotrol Difficulty walkig Difficulty speakig or slurred speech Progressive or sudde impairmet of cosciousess Bleedig or draiage of fluid from the ose or ears Ay other abormal behavior ad/or sig or symptom If ay of the above occurs call a ambulace or take the athlete to the hospital Emergecy Room. Emergecy Phoe Numbers: EMS- 911 Athletic Traiig Room: Paret/ Guardia Cotact: Yes No Notes: Athletic Traier: YISD athletes who have sustaied a cocussio will be required to follow up with their licesed athletic traier or middle school coach each day util cleared by a physicia. Although cleared by a physicia, the athlete must still pass the (progressive retur to play) protocol before they will be cosidered for release to full activity. (HB 2038, Tasha s Law) Studet Sigature: Paret/Guardia Sigature: White - Athlete Date: Date: Yellow - School I

25 UIL Retur to Play Studet/Paret Coset Form Cocussio Maagemet Protocol Retur to Play Form This form must be completed ad submitted to the athletic traier or other perso (who is ot a coach) resposible for compliace with the Retur to Play protocol established by the school district Cocussio Oversight Team, as determied by the superitedet or their desigee (see Sectio (c) of the Texas Educatio Code). Studet Name (Please Prit) School Name (Please Prit) Desigated school district official verifies: Please Check The studet has bee evaluated by a treatig physicia selected by the studet, their paret or other perso with legal authority to make medical decisios for the studet. The studet has completed the Retur to Play protocol established by the school district Cocussio Oversight Team. The school has received a writte statemet from the treatig physicia idicatig, that i the physicia s professioal judgemet, it is safe for the studet to retur to play. School Idividual Sigature Date School Idividual Name (Please Prit) Paret, or other perso with legal authority to make medical decisios for the studet sigs ad certifies that he/she: Please Check Has bee iformed cocerig ad cosets to the studet participatig i returig to play i accordace with the retur to play protocol established by the Cocussio Oversight Team. Uderstads the risks associated with the studet returig to play ad will comply with ay ogoig requiremets i the retur to play protocol. Cosets to the disclosure to appropriate persos, cosistet with the Health Isurace Portability ad Accoutability Act of 1996 (Pub. L. No ), of the treatig physicia s writte statemet uder Subdivisio (3) ad, if ay, the retur to play recommedatios of the treatig physicia. Uderstads the immuity provisios uder Sectio of the Texas Educatio Code. Paret/Resposible Decisio-Maker Sigature Date Paret/Resposible Decisio-Maker Name (Please Prit)

26 YISD Cocussio Reportig Form Date of Cocussio Sport Geder Level of Competitio Evet Date of Physicia Release Date Passed Progressive Retur Protocol Ex. 7/22/2011 Baseball Male Varsity No-School Sport Related 7/26/2011 8/5/

27 Physicia Iformatio Yoakum ISD Retur to Play Guidelies Iformatio for Treatig Physicia Yoakum ISD has developed a protocol for maagig cocussios as per HB 2038 Tasha s Law. This policy icludes a multidisciplie approach ivolvig athletic traier clearace, physicia referral ad clearace, ad successful completio of activity progressios related to their sport. The followig is a outlie of this procedure. All athletes who sustai head ijuries are required to be evaluated by a physicia. They must have a ormal physical ad eurological exam prior to beig permitted to progress to activity. 1. The studet will be moitored daily at school by the athletic traier. Accommodatios may eed to be give accordig to physicia recommedatios ad observatios. 2. The studet must be asymptomatic at rest ad with exertio. 3. Oce cleared to begi activity, the studet will start a progressive retur to play protocol. The progressios will advace i 24 hour itervals. The progressios are: Level 1- Light aerobic exercise- 5 to 10 miutes o a exercise bike or light jog; o weight liftig, resistace traiig, or ay other exercise. Level 2- Moderate aerobic exercise miutes of ruig at moderate itesity i the gym or o the field without a helmet or other equipmet. Level 3- No- cotact traiig drills i full uiform. May begi weight liftig, resistace traiig, ad other exercises. Level 4- Full cotact practice or traiig. Level 5- Full game play. Note Athlete progressio cotiues as log as athlete is asymptomatic at curret activity level. If the athlete experieces ay post cocussio symptoms, he/she will wait 24 hours ad start the progressios agai at the begiig. For full release to play a physicia release, paret/ athlete siged coset ad a progressive retur to play protocol must be completed ad o file.

28 YISD FERPA Release Form I YOAKUM ISD Authorizatio for the Release of Medical Iformatio The Family Educatio Right to Privacy Act (FERPA) is a federal law that govers the release of a studet s educatioal records, icludig persoal idetifiable iformatio (ame, address, social security umber, etc.) from those records. Medical iformatio is cosidered a part of a studet athlete s educatioal record. This authorizatio permits physicias to disclose iformatio cocerig my medical status, medical coditio, ijuries, progosis, diagosis, ad related persoal idetifiable health iformatio to the authorized parties as follows: the athletic traiers, team physicias, ad athletic staff (icludig coaches) of the Yoakum ISD. This iformatio icluded ijuries or illesses relevat to past, preset, or future participatio i athletics. The purpose of a disclosure is to iform the authorized parties of the ature, diagosis, progosis or treatmet cocerig my medical coditio ad ay ijuries or illesses. I uderstad oce the iformatio is disclosed it is subject to re-disclosure ad is o loger protected. I uderstad that the Yoakum ISD will ot receive compesatio for its disclosure of the iformatio. I uderstad that I may refuse to sig this authorizatio ad that my refusal to sig will ot affect my ability to obtai treatmet. I may ispect or copy ay iformatio disclosed uder this authorizatio. I uderstad that I may revoke this authorizatio at ay time by providig writte otificatio to the head athletic traier Yoakum ISD. I uderstad revocatio will ot have ay effect o actios Yoakum ISD has take i reliace o this authorizatio prior to receivig the revocatio. This authorizatio expires six years from the date it is siged. Studet ID# Prited Name of Studet: Studet Sigature: Prited Name of Paret: Paret Sigature:_ White - School Yellow - Athlete I

29 Cocussios (Tasha s Law - HB 2038) Cocussios (Tasha s Law- HB 2038) Report All Head Ijuries Remove from Activity Immediately Paret/ Guardia Cotact Physicia Release Paret/ Athlete Release Progressive Retur to Play Protocol 1) Light Aerobic 2) Moderate Aerobic 3) No Cotact Practice 4) Full Cotact Practice 5) Full Game