Pleasantville School District Concussion Procedures of Parents

Size: px

Start display at page:

Download "Pleasantville School District Concussion Procedures of Parents"

Martha Booker
5 years ago
Views:

1 Pleasantville School District Concussion Procedures of Parents This document is a brief outline on concussions and the procedure the district follows when a student suffers a concussion. By New York State Law, the School Physician, Dr. Kristin Roye, must give final clearance to begin the Return to Play Procedure and full return. The treating physician must fill out the Physician Evaluation Form to be reviewed by Dr. Roye. Concussion Procedure: A. All secondary-school athletes are required to take the Baseline ImPACT concussion test every 2 years, in 7 th /9 th /11 th grade, or 8 th /10 th /12 th grade (see website for information and directions). B. A student suffers a head injury and has signs/symptoms of a concussion: 1. The Athletic Trainer/Nurse gives the parent(s) a concussion packet including a Take Home Information Sheet, Heads Up Information Sheet, and Physician Evaluation Form. 2. The student will be evaluated by a physician for formal concussion diagnosis. a. The student will bring the filled out Physician Evaluation Form to the Nurse or Athletic Trainer. 3. The student will rest from gym and athletics until otherwise directed, and classroom accommodations may be recommended by the physician. 4. Post-inury ImPACT testing should be administered within hours of the injury under the direction of the Athletic Trainer, unless otherwise instructed by treating physician. 5. The student will return to the physician for follow-up evaluation. a. The second portion of the Physician Evaluation Form should be completed by the physician and returned to the Nurse or Athletic Trainer. b. If cleared by treating physician to begin the Return to Play Progression, Dr. Roye will review and provide final clearance. 6. The student will complete the Return to Play Progression. a. High schoolers/middle school athletes: supervised by Athletic Trainer. b. Middle Schoolers: supervised by Physical Education teacher. 7. Once the progression is completed, Dr. Roye will review and provide final clearance for full return to play. Any questions regarding concussion management may be addressed to the Athletic Trainer, Justen Lopez: atc.pville@proclinix.com

2 Pleasantville School District Take Home Concussion Instructions I believe that has/may have sustained a concussion on. In some instances, the signs of a concussion do not become obvious until several hours or even days after the injury. Please be observant for the following signs and symptoms. 1. Headache (especially one that increases in intensity*) 2. Nausea or vomiting* 3. Decreased or irregular pulse OR respiration* 4. Seizure activity* 5. Slurred speech* 6. Blurry or double vision* 7. Changes in the level of consciousness (difficulty awakening)* 8. Dizziness 9. Memory loss 10. Ringing in the ears 11. Changes in gait or balance *Call for medical attention at the nearest emergency department* Things that are OK: Things that are not OK: Things there are no need to do: Take Tylenol Physical activity/driving Check eyes with a flashlight Use ice packs as needed Watch TV, video games, listen to Wake up every hour Eat a light diet ipod or use phone, computer Test reflexes Go to sleep Return to school if ready Heavy reading, bright lights/loud noises Eat spicy food If your son/daughter is seen by a physician, you MUST have the Physician Evaluation Form completed and signed. Have the student report to the school nurse tomorrow morning for a follow-up exam. If you have any non-emergent questions, contact the Athletic Trainer, Justen Lopez, at the number below. Further recommendations: Recommendations provided by: Date: Time: Contact:

PARENT & ATHLETE CONCUSSION INFORMATION SHEET WHAT IS A CONCUSSION? A concussion is a type of traumatic brain injury that changes the way the brain normally works.

Even a ding, getting your bell rung, or what seems to be a mild bump or blow to the head can be serious. WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?

If an athlete reports one or more symptoms of concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury.

3 PARENT & ATHLETE CONCUSSION INFORMATION SHEET WHAT IS A CONCUSSION? A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a ding, getting your bell rung, or what seems to be a mild bump or blow to the head can be serious. WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION? Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If an athlete reports one or more symptoms of concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury. The athlete should only return to play with permission from a health care professional experienced in evaluating for concussion. DID YOU KNOW? Most concussions occur without loss of consciousness. Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion. Young children and teens are more likely to get a concussion and take longer to recover than adults. SYMPTOMS REPORTED BY ATHLETE: Headache or pressure in head Nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light Sensitivity to noise Feeling sluggish, hazy, foggy, or groggy Concentration or memory problems Confusion Just not feeling right or is feeling down SIGNS OBSERVED BY COACHING STAFF: Appears dazed or stunned Is confused about assignment or position Forgets an instruction Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness (even briefly) Shows mood, behavior, or personality changes Can t recall events prior to hit or fall Can t recall events after hit or fall [ INSERT YOUR LOGO ] IT S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON

4 Student s Name Physician Evaluation Date of First Evaluation: Date of Second Evaluation: Time of Evaluation: Time of Evaluation: Symptoms Observed: First Doctor Visit Second Doctor Visit Dizziness Yes No Yes No Headache Yes No Yes No Tinnitus Yes No Yes No Nausea Yes No Yes No Fatigue Yes No Yes No Drowsy/Sleepy Yes No Yes No Sensitivity to Light Yes No Yes No Sensitivity to Noise Yes No Yes No Anterograde Amnesia Yes No N/A N/A (after impact) Retrograde Amnesia Yes No N/A N/A (backwards in time from impact) * Please indicate yes or no in your respective columns. First Doctor use column 1 and second Doctor use column 2. First Doctor Visit: Did the athlete sustain a concussion? (Yes or No) (one or the other must be circled) ** Post-dated releases will not be accepted. The athlete must be seen and released on the same day. Please note that if there is a history of previous concussion, then referral for professional management by a specialist or concussion clinic should be strongly considered. Additional Findings/Comments: Recommendations/Limitations: Signature: Date: Print or stamp name: Phone number: Second Doctor Visit: *** Athlete must be completely symptom free in order to begin the return to play progression. If athlete still has symptoms more than seven days after injury, referral to a concussion specialist/clinic should he strongly considered. Please check one of the following: Athlete is asymptomatic and is ready to begin the return to play progression. Athlete is still symptomatic more than seven days after injury. Signature: Date: Print or stamp name: Phone number:

5 SCHOOL RECOMMENDATIONS FOLLOWING CONCUSSION Patient Name: Date of Birth: Date of Evaluation: Referred by: Duration of Recommendations: 1 week 2 weeks 4 weeks Until further notice The patient will be reassessed for revision of these recommendations in weeks. This patient has been diagnosed with a concussion (a brain injury) and is currently under our care. Please excuse the patient from school today due to the medical appointment. Flexibility and additional supports are needed during recovery. The following are suggestions for academic adjustments to be individualized for the student as deemed appropriate in the school setting. Feel free to apply/remove adjustments as needed as the student s symptoms improve/worsen. Attendance Breaks No school for school day(s) Allow the student to go to the nurse s Attendance at school days per week office if symptoms increase Full school days as tolerated by the student Allow student to go home if symptoms do Partial days as tolerated by the student not subside Allow other breaks during school day as deemed necessary and appropriate by school personnel Visual Stimulus Audible Stimulus Allow student to wear sunglasses/hat in school Lunch in a quiet place with a friend Pre printed notes for class material or note taker Avoid music or shop classes Limited computer, TV screen, bright screen use Allow to wear earplugs as needed Reduce brightness on monitors/screens Allow class transitions before bell Change classroom seating as necessary Workload/Multi Tasking Testing Reduce overall amount of make up work, class Additional time to complete tests work and homework No more than one test a day Prorate workload when possible No standardized testing until Reduce amount of homework given each night Allow for scribe, oral response, and oral delivery of questions, if available Physical Exertion Additional Recommendations No physical exertion/athletics/gym/recess Walking in gym class only Begin return to play protocol as outlined by return to activity form Current Symptoms List (the student is noting these today) Headache Visual problems Sensitivity to noise Memory issues Nausea Balance problems Feeling foggy Fatigue Dizziness Sensitivity to light Difficulty concentrating Irritability Student is reporting most difficulty with/in All subjects Reading/Language arts Foreign Language Math Science Music History Using Computers Focusing Listening Other: XXXXXXXXXXXX, MD XXXXXXXXXXXXXXXXXXXX Office (XXX)XXX XXXX Fax (XXX)XXX XXXX I,, give permission for Dr. XXXXXXXXX to share the following information with my child s school and for communication to occur between the school and Dr. XXXXXXX for changes to this plan Parent Signature Date This form may be duplicated or changed to suit your needs and your patients needs.

2017 Youth Soccer Program

Central Klickitat County Parks and Recreation District 2017 Youth Soccer Program For girls and boys ages 4 14 Age division will be determined by child s date of birth on July 31, 2017 Registration forms