INFORMATION AND SIGNATURE FORM
FOR STUDENT-ATHLETES & PARENTS/LEGAL GUARDIANS
(Adapted from CDC “Heads Up Concussion in Youth Sports”)
Public Chapter 148, effective January 1, 2014, requires that school and community organizations sponsoring youth athletic activities establish guidelines to inform and educate coaches, youth athletes and other adults involved in youth athletics about the nature, risk and symptoms of concussion/head injury.
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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 rapidly 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.
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.
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 listed below after a bump, blow or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care provider* says s/he is symptom-free and it’s OK to return to play.
SIGNS OBSERVED BY COACHING STAFF = SYMPTOMS REPORTED BY ATHLETES
> Appears dazed or stunned = Headache or “pressure” in head
> Is confused about assignment or position = Nausea or vomiting
> Forgets an instruction = Balance problems or dizziness
> Is unsure of game, score or opponent = Double or blurry vision
> Moves clumsily = Sensitivity to light
> Answers questions slowly = Sensitivity to noise
> Loses consciousness, even briefly = Feeling sluggish, hazy, foggy or groggy
> Shows mood, behavior or personality changes = Concentration or memory problems
> Can’t recall events prior to hit or fall = Confusion
> Can’t recall events after hit or fall = Just not “feeling right” or “feeling down”
*Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training