The Rothman Institute is currently offering an innovative program for student-athletes called ImPACT. ImPACT (Immediate Post Concussion Assessment and Cognitive Testing) is a software tool which includes a computerized exam utilized in many professional, collegiate, and high school programs across the country to successfully manage concussion. In our program, the computerized exam will be given to student-athletes before beginning contact sports practice or competition to establish a personal baseline. This non-invasive screening is set up in a “video game type” format and can be taken at home. Each athlete will be sent a code via email to complete the baseline test. It is a simple exercise which tracks information such as memory, reaction time, speed time, speed and concentration. It is not an IQ test and this initial baseline is NOT used for diagnosis of any kind. Rather, it simply serves as a baseline point of comparison to be used after a concussion is suspected.

If a concussion is suspected, the athlete may then go to a CIC (Credentialed ImPACT Consultant) physician at the Rothman Institute or another center and retake the computerized exam. Then both the baseline and the post-injury test can be used by the physician to help evaluate the injury. The test data will be a factor in the determination whether return to play is appropriate and safe for the injured athlete. We are excited to offer this program and to offer a baseline exam for student-athletes to measure against post-injury. Please review the attached consent form and return with the appropriate signature(s If you have any further questions, please contact Jessica Kempa at (267) 463-2288.

I consent to voluntarily participate in the Rothman ImPACT screening program which I am aware will provide a personal baseline only and is not diagnostic. I have taken the time to review the letter provided by the Rothman Institute regarding this baseline program and all of my questions have been answered to my satisfaction.

I hereby state that to the best of my knowledge I have no medical, mental or physical conditions that may restrict me from

completing the on-line ImPACT screening.

I understand that to the best of my knowledge I will report all information regarding past medical history, especially

concussions, with the ImPact baseline screen.

I understand that the information provided by this baseline screen is only a baseline and does not represent medical advice, analysis, diagnosis or treatment. If injured, I agree to have an in-person evaluation by a medical physician trained in concussion management to review the results of post-injury ImPACT testing. This physician will make any diagnostic or

return to play decisions at that time.

I understand that the baseline screening alone will not be interpreted by a medical professional at the time of testing and

cannot be used to make any diagnosis.

I understand that regardless of any ImPACT testing, any time an individual is suspected of sustaining a traumatic brain injury or concussion the individual should immediately seek the advice of a qualified and trained health care provider and be monitored closely for any signs and symptoms of a head injury. I also agree to be evaluated in person by a physician if I

develop any signs or symptoms of a concussion at any time.

I HAVE READ THIS CONSENT TO CONDUCT IMPACT SCREENING, AS WELL AS THE LETTER FROM THE ROTHMAN INSTITUTE DESCRIBING THE SCREENING. I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK ANY QUESTIONS I HAVE AND I FULLY CONSENT TO ALL OF THE TERMS AND CONDITIONS.

IF THE PERSON PARTICIPATING IN THE ACTIVITY IS NOT 18 YEARS OLD, AS THE PARENT OR LEGAL GUARDIAN OF THE ABOVE MENTIONED INDIVIDUAL, I VERIFY THAT I HAVE READ THE CONSENT TO CONDUCT IMPACT SCREENING, AS WELL AS THE LETTER DESCRIBING THE IMPACT SCREENING,I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK ANY QUESTIONS I HAVE AND I FULLY CONSENT TO ALL OF THE TERMS AND CONDITIONS OF THIS CONSENT.