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Coaches Concussion Form

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CONCUSSION

INFORMATION AND SIGNATURE FORM FOR COACHES

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 and head injury.

(Adapted from CDC “Heads Up Concussion in Youth Sports”)  

Sign and return this page.

____  I have read the Concussion Information and Signature Form for Coaches

____  I should not allow any student-athlete exhibiting signs and symptoms consistent with concussion to return to play or practice on the same day.

After reading the Information Sheet, I am aware of the following information (Initial each statement):

_____  A concussion is a brain injury.

_____  I realize I cannot see a concussion, but I might notice some of the signs in a student-athlete right away. Other signs/symptoms can show up hours or days after the injury.

_____ If I suspect a student-athlete has a concussion, I am responsible for removing  him/her from activity and referring him/her to a medical professional trained in concussion management.

_____ Student-athletes need written clearance from a health care provider* to return to  play or practice after a concussion. * (Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training)

_____ I will not allow any student-athlete to return to play or practice if I suspect that he/she has received a blow to the head or body that resulted in signs or symptoms consistent with concussion.

_____ Following concussion the brain needs time to heal. I understand that student-athletes are much more likely to sustain another concussion or more serious brain injury if they return to play or practice before symptoms resolve.

_____ In rare cases, repeat concussion can cause serious and long-lasting problems.

_____ I have read the signs/symptoms listed on the Concussion Information and Signature Form for  Coaches.

________________________________________                    _____________________

Signature of Coach                                                                   Date

_____________________________________________

Printed name of Coach

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