UNIVERSITY OF SOUTH FLORIDA ATHLETICS TRYOUT CLEARANCE FORM. PHYSICAL FORM: physical form must be validated with a stamp from the physician s office.

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1 Welcome to the University of South Florida and its Intercollegiate Athletics Program. Prior to your Tryout it is necessary for us to gather pertinent medical information in order to determine if you are medically eligible to participate in intercollegiate athletics. Enclosed, you will find a packet of forms that require your attention. When completing these forms, please answer all questions to the best of your knowledge. Below is a list of forms followed by a brief description. If you have any questions, please feel free to contact one of the athletic training staff members via the numbers listed below. You are required to have completed in a comprehensive physical exam given by a qualified general medical physician. The physical form must be stamped by the clinic you receive your physical from. Unstamped physical forms will not be accepted as a valid physical. UNIVERSITY OF SOUTH FLORIDA ATHLETICS TRYOUT CLEARANCE FORM PHYSICAL FORM: physical form must be validated with a stamp from the physician s office. MEDICAL HISTORY: This will inform us of any previous medical problems and hopefully prevent any further problems from occurring. HEALTH INSURANCE INFORMATION FORM: A photocopy of both sides of all insurance cards (medical, dental, vision, prescription) must be attached to the completed form. STUDENT-ATHLETE PERSONAL INFORMATION FORM: This form provides contact information in the event of an emergency. BIOLOGICAL TESTING CONSENT FORM: By signing this form, you are indicating your understanding of the program and your agreement to be screened for banned substances. Screening takes place randomly throughout the year for all athletes. Participation in athletics is contingent upon adherence to the program and the signing of the consent form. INFORMATION RELEASE AUTHORIZATION FORMS: These forms gives the athletic training staff permission to release your medical history to team physicians, coaches, athletic staff members, student athletic trainers, parent(s)/ guardian(s), teammates, and professional scouts. These forms are required to be completed only once during your athletic career at USF. NCAA AND USF POLICY REGARDING LIABILITY: This form allows us to provide emergency medical care to you and terminate participation for health reasons at any time. NOTICE OF PATIENT INFORMATION PRIVACY PRACTICES: This form is informative and may be kept for your records. The notice explains your rights as a patient and how the USF Sports Medicine staff may use your medical information. Please return the acknowledgement page. SICKLE CELL TESTING: As of 2010, the NCAA mandates that every athlete be tested for sickle cell trait. Before you are allowed to try out, you must either have the results of your test or sign the waiver that will be provided when this packet is turned in. CONCUSSION MANAGEMENT PROTOCOL: this document states that you have where provided and read the information provide on the NCAA and National Athletic Trainers Association recommendations on Concussion Management. If you have any questions please feel free to contact one of us at in the Athletic Training room at (813)

2 Tryout Clearance Form I,, understand that there are risks in trying out for the sport of. I am voluntarily assuming the responsibility for any such risks and I will be liable for any injury that I may incur during or as a result of my participation in this tryout. I assume full financial and legal responsibility for any injury/ or injuries suffered by me during any tryout(s). There is no health related reason(s) or problem(s) which preclude or restrict my participation in this tryout. I also consent to receive any emergency medical treatment deemed necessary by the Sports Medicine staff at the University of South Florida and agree that the Sports Medicine staff may terminate my participation in the tryout for any time and for any reason. I waive and release the University of South Florida, the Board of Trustees, and the officers, agents, employees, and any students acting on behalf of either the University of South Florida or the Board of Trustees, and their heirs, assigns, or successors in interest of any and each of them from any and all Liability which may result or arise from my participation in any tryout(s) or from any emergency treatment I may receive during the tryout(s). If any portion of this Release is held to be illegal, unenforceable, or in conflict with any laws of the State of Florida by any Court of competent jurisdiction, the remaining portions of this release shall not be affected. Signature Print Name Sports Medicine Approval Signature of Parent/Guardian if Participant is under 18 years of age Enrolled Full Time? Yes No Degree Seeking Student? Yes No The above named student is approved to tryout for a maximum of seven (7) days without further approval.

3 PRE-PARTICIPATION PHYSICAL EXAMINATION Name: of Birth: / / : Sport: Height: (inches) Weight: (lbs.) B.P. / Pulse: Vision: R 20/ L 20/ Corrected: Glasses/Contacts Pupils: Equal / Unequal SAC Result: /30 General Appearance Eyes NORMAL ABNORMAL FINDINGS Ears Nose Throat/Mouth Neck Heart Lungs Abdomen Hernia G.U. Other General Medical Clearance: Cleared to Participate? Yes / No Evaluating Physician: Further Evaluation Needed? Yes / No Explain: Reviewing Physician:

4 PRE-PARTICIPATION PHYSICAL EXAMINATION Name: of Birth: / / : Sport: Neck NORMAL ABNORMAL FINDINGS Back Shoulder/Arm Elbow/Forearm Wrist/Hand/ Fingers Hip/Groin Thigh Knee Lower Leg Ankle Foot Orthopaedic Clearance: Cleared to Participate? Yes / No Evaluating Physician: Further Evaluation Needed? Yes / No Explain:

5 MEDICAL HISTORY Name of Birth / / Sport Family History Does anyone in your family have a history of medical problems? If yes, explain: Mother: Living: Age of Death: Cause of Death: Father: Living: Age of Death: Cause of Death: Brother(s): Living: Age of Death: Cause of Death: Sister(s): Living: Age of Death: Cause of Death: Has anyone in your family ever been diagnosed with: Sudden unexplained death Relationship: Explain: Alcohol/Substance Abuse Relationship: Explain: Asthma Relationship: Explain: Cancer Relationship: Explain: Diabetes Relationship: Explain: Heart Disease (of any kind) Relationship: Explain: High Blood Pressure Relationship: Explain: Marfan Syndrome Relationship: Explain: Migraines/Severe Headaches Relationship: Explain: Osteoporosis/Bone Disorder Relationship: Explain: Seizures/Epilepsy Relationship: Explain: Sickle Cell Disease/Trait Relationship: Explain:

6 Current Medical Conditions: Are you currently under medical supervision for an injury/illness? If yes, explain: Do you have a current ongoing or chronic illness? If yes, explain: Surgery/Hospitalization: Have you ever had surgery? : : : Surgery: Surgery: Surgery: Have you ever been hospitalized for a reason other than surgery? : Reason: : Reason: Have you ever been advised to have a surgery not yet performed? If yes, explain: Medications: Do you regularly use any prescription medication? If yes, explain: Do you regularly use non-prescription medication? If yes, explain: Do you regularly take any dietary supplements? If yes, explain: Have you ever taken supplements or vitamins to help you gain/lose weight in order to improve your performance? If yes, explain: Alleriges: Are you allergic to any of the following: Aspirin Food (specify) Dust/pollen Insect stings (specify) Penicillin Sulfa Drugs Novocaine Other Drugs (specify)

7 Illnesses: Have you had any of the following illnesses: Chicken Pox : Diabetes : Hepatitis : Measles : Mononucleosis Mono : Pneumonia : Have you ever had any of the following: Anemia Sickle Cell Disease/ Sickle Cell Trait Eye injury or other eye problem Hearing loss Severe tooth or gum trouble Severe skin problems (rash, acne, burns, etc.) Do you have loss or seriously impaired function of any paired organ? Ear Eye Kidney Ovary Testicle Lung Cardiovascular System: Do you get more fatigued (tired) during exercise, or get fatigued earlier during exercise than your teammates? Do you become more short of breath during exercise than your teammates? Have you ever fainted or passed out during or after exercise? Have you ever had chest pains during or after exercise? Have you ever been told that you have high blood pressure (hypertension)? Have you ever been told that you have a heart murmur? Have you ever been told that you had high cholesterol (hyperlipidemia)? Has a physician ever ordered heart testing (for example: EKG, Echo, stress test, holter monitor)? If yes, please explain: Have you ever been diagnosed with any type of heart disease (hypertrophic cardiomyopathy, coronary artery abnormality, heart infection, heart valve disease, Marfan s Syndrome, etc)? If yes, please specify: Have you ever been told that you need to take medication before seeing a dentist? Have you ever had a racing heart or skipped heart beats? Has anyone in your family died of heart problems or sudden death before the age of 50? If you answered yes to any of the above questions, please explain:

8 Respiratory System: Do you cough, wheeze, have difficulty breathing, or get short of breath during exercise? If yes, how often? Have you ever been diagnosed with asthma? If so, is your asthma well controlled? Please check one: I have symptoms from my asthma: daily More than twice per week Less than twice per week Hardly ever Do you use an inhaler? If yes, what kind? Do you have seasonal allergies that require medical treatment or medication? Neurological System: Have you ever had a head injury or a concussion? : Explain: If so, how many concussions? Have you ever been knocked out, unconscious, or lost your memory? : Explain: Have you ever had a seizure? : Explain: Have you ever had a stinger, burner, or pinched nerve? : Explain: Heat Illnesses: Have you ever had heat stroke or heat exhaustion? If so, please explain: Have you ever had muscle cramps caused be the heat? How often? Have you ever been dizzy or fainted in the heat? How often? Have you ever been confused in the heat? How often? Have you ever been hospitalized for a heat related condition? Nutrition: Do you want to weigh more or less than you currently do? Do you frequently lose weight or gain weight to meet the requirements of your sport? Would you be interested in seeing a sports nutritionist? Have you ever been told you were Anemic by a physician?

9 Women Only: What was the date of your last menstrual period? When was your first menstrual period? How many periods have you had in the last year? What was the longest time between periods in the last year? My periods are now (circle one): Regular every days Irregular every 36 days or more Absent no periods for the past three months Are you currently taking a form of birth control? If yes, what kind? Is there a history of osteoporosis in your family? Is there a history of repeated fracture in anyone in your family? Have you had repeated fractures or repeated stress fractures before? Protective Devices: Do you wear contacts? Do you wear glasses? Do you wear orthotics in your shoes? Do you wear any corrective braces or supports? If yes, what? Musculoskeletal System: Have you ever injured any of the following extremities that caused you to miss a week or more participation in your sport? Hip Left / Right : Explain: Groin Left / Right : Explain: Thigh Left / Right : Explain: Knee Left / Right : Explain: Shin/Calf Left / Right : Explain: Ankle Left / Right : Explain: Foot/Toes Left / Right : Explain: Skull/Face Left / Right : Explain: Teeth/Jaw Left / Right : Explain: Neck Left / Right : Explain: Back Left / Right : Explain: Shoulder Left / Right : Explain: Upper Arm Left / Right : Explain: Elbow Left / Right : Explain: Forearm Left / Right : Explain: Wrist Left / Right : Explain: Hand/Fingers Left / Right : Explain:

10 MENTAL HEALTH HISTORY How often do you experience the following emotions? (Circle appropriate number from 1 never to 5 often) Never Often Depression Anxiety Anger or Short Temper Feeling of Isolation Fatigue Low Self-Esteem Do you currently or have you ever had the following feelings about activities that you enjoy? Helplessness, loss of interest Yes No Overly irritable Yes No Mood Swings Yes No Problems with Concentration Yes No Do you experience? Racing thoughts Yes No Racing heartbeat Yes No Over worry Yes No Anticipate the worst Yes No Feel stressed of tense Yes No Feelings of loneliness or homesickness Yes No Do you have problems sleeping?nightmares? Yes No Have you ever been diagnosed with a learning disability? Yes No Do you have or have you ever been diagnosed and/or treated for attention deficit or hyperactivity? Yes No Do you have or have you ever been diagnosed and/or treated for substance or alcohol abuse? Yes No Do you have or have you ever been diagnosed and/or treated with an eating disorder? Yes No Do you have or have you ever been treated for a psychiatric condition (depression, anxiety, etc)? Yes No Are you currently taking medication for any of the above conditions? Yes No Medication

11 Other Medical Conditions: Have you ever been told, for any reason that you should not participate in sports? If yes, explain: Do you know of, or believe, there is any reason that should prevent you from participating in intercollegiate athletics? If yes, explain: I certify that the answers to the preceding questions are correct and true to the best of my knowledge. I understand that passing the physical exam does not necessarily mean that I am physically qualified to engage in intercollegiate athletics, but only that the examiner did not find medical reason to disqualify me from participation. Signature of Student-Athlete Signature of Parent/Guardian if under 18 years of age MEDICAL CONSENT Permission is hereby granted to the attending physician, USF Sports Medicine Staff, or other medical personnel to proceed with medical treatment, minor surgical treatment, and x-ray examination. In the event of serious injury or illness, I understand that an attempt will be made by the appropriate medical personnel to contact my parents or legal guardian. If medical personnel are not able to communicate with the responsible party, the treatment necessary for my health will be provided. Signature of Student-Athlete Signature of Parent/Guardian if under18 years of age

12 Student-Athlete Health Insurance Information Form Dear Parent/Guardian: We have an established athletic insurance policy providing medical coverage for your son/daughter for injuries that occur while participating in Intercollegiate Athletics. This medical coverage is secondary to medical/dental/vision insurance provided by the parent/guardian. After primary benefits are considered, USF will process the remaining balance for payment. Please complete this form entirely. Please attach copies of all insurance cards, front and back. StudentAthlete Sport DOB USF I.D. Local Phone Number ( ) Cell Phone Number ( ) If Uninsured initial here: Insurance Subscriber Name SS# DOB Address Employer Work.Phone Athlete s Relationship to Subscriber Primary Medical Insurance Insurance.Company Customer.Service# Claims.Address Member# Policy# Group# PPO or HMO Primary Care Physician Phone# Secondary Insurance (circle one) Prescription, Dental, Vision Insurance.Company Customer.Service# Claims.Address Member# Policy# Group# PPO or HMO Primary Care Physician Phone# Secondary Insurance (circle one) Prescription, Dental, Vision Insurance.Company Customer.Service# Claims.Address Member# Policy# Group# PPO or HMO Primary Care Physician Phone# IN CASE OF EMERGENCY CALL Name: Relationship: Address: Home Phone #: ( ) Cell Phone #: ( ) Work Phone #: ( ) I acknowledge receiving the University of South Florida s intercollegiate athletic medical policy. I understand the university s responsibility to a student athlete who becomes injured or ill as a result from participation in intercollegiate athletics. Student Athlete s Signature: (date)

13 BIOLOGICAL SPECIMEN TESTING CONSENT FORM 1. I hereby consent to be tested to determine if I have utilized any substance on the University of South Florida list of banned drug classes as set forth in the University of South Florida s Substance and Abuse Policy, by providing a biological specimen as requested by the director of intercollegiate athletics or designee. 2. I agree to provide such biological specimens at the time and location and under conditions for collection, as determined by the director of intercollegiate athletics or designee, at various times throughout the year, with or without prior notice. 3. I hereby authorize the director of intercollegiate athletics or designee to send my samples to the laboratory of the university s choice for actual testing and authorize the director of intercollegiate athletics or designee to receive test results. 4. I hereby authorize the director of intercollegiate athletics or designee to release all information and records, including test results, that may be made or received relating to the screening and testing of my biological specimens to the university s respective head coach and associate athletic director for sports and program services, or their designees, for their use in supervision and administration of the university s athletic program. I acknowledge that while certain medical information may be released to the media by virtue of my participation in USF Intercollegiate Athletics, the results of drug tests will not be released or reported. I further acknowledge and agree that my parent/ guardian will be notified of the results of any positive test result(s). 5. I acknowledge that I have read a copy of the University of South Florida Drug Abuse Policy and Procedures, including the University of South Florida Banned Drug Class List, and that I have had an opportunity to ask questions regarding them. I understand the provisions therein and I agree to abide by those provisions including those specifically related to possible penalties for positive test results. 6. I hereby release and discharge the University of South Florida and the Board of Trustees of the State University System of South Florida, their officers, employees and agents from all claims and causes of action created by or arising out of any act or omission related to the implementation of the University of South Florida Drug Abuse Policy and procedures. 7. I have read this Consent Form, understand the terms in it, their legal significance and sign voluntarily. 8. I understand that I may revoke my consent to participate at any time in the University of South Florida Drug Abuse Policy. In doing so, I understand and agree that I will immediately be banned from participation in intercollegiate athletics at University of South Florida and will immediately forfeit any related athletic scholarships or financial aid. Student Athlete Name (Print) USF ID Number Student-Athlete Signature Birth Parent / Guardian (if under 18 years of age) Sport

14 INFORMATION RELEASE AUTHORIZATION I,, Give consent for my medical records to be released to any USF Team physician involved in the care of my illness or injury; or to a physician appointed by the USF Athletic Training Staff. Athlete s Signature: : / / I also give consent for the USF Athletic Training Staff to release medical information to the sports information department, media, or a scout/ representative of any professional or amateur athletic organization seeking such information. I acknowledge that this type of information may be reported in the media as a result of my participation in USF Intercollegiate Athletics, except that no results of drug tests will be released or reported. Body part affected by injury or illness Nature of the injury (sprain, fracture, etc.) Status of the athlete for same day and future competition Athlete s Signature: : / / ***This release remains valid until revoked in writing and delivered to the Assistant Director of Athletics for Sports Medicine. For purposes of this authorization, medical information can include but not be limited to, information concerning illness, injury, treatment, rehabilitation, physicians names or referrals, and/or prognosis.

15 SUPPLEMENT/MEDICATION WAIVER I will not consume any nutritional supplement* other than those provided or having written approval from Athletic Department Sport Performance staff, Assistant AD/Head Strength & Conditioning Coach or Assistant AD/Director of Sports Medicine. I will notify Sports Medicine staff and Team Physicians of any current prescription medications I am presently taking prior to receiving any OTC* and Prescription medications* from Sports Medicine staff. *Nutritional supplement is any product (powder, pill, liquid, beverage, tablet, etc.) designed to supplement the diet which includes one or more of the following ingredients: vitamins, minerals, herbs, botanicals, amino acids, calorie boosters, constituents, extracts, or any combination of these ingredients. *OTC medications are medications that can be purchased over the counter from retailers such as drug stores, pharmacies, grocery stores and convenience stores. A prescription is not needed for these medications. Typical OTC medications include Tylenol, aspirin, ibuprofen, cough and cold formulas, and medications for allergies, constipation, diarrhea and nausea. *Prescription medications are generally more potent than those sold over-the-counter (OTC) and may have more serious side effects if inappropriately used. Therefore, these medications are only sold under a doctor s direction. All supplements must be approved by the three individuals listed above. Please list supplements/medication you are currently taking or have taken in the past 3 months: Print Name: Signature: :

16 LIABILITY WAIVER I,, understand that there are risks in participating in the sport of. I am voluntarily assuming the responsibility for any such risks. Therefore, I consent to receive any emergency medical treatment deemed necessary by the Sports Medicine staff at the University of South Florida and agree that the Sports Medicine staff may terminate my participation at any time and for any reason. I waive and release the University of South Florida, the Board of Trustees (or any other entity designated by Florida law to manage, operate, and/or oversee the University of South Florida) and the officers, agents, employees, and any students acting on behalf of either the University of South Florida or the Board of Trustees, and the heirs, assigns or successors in interest of any and each of them from any and all Liability which may result or arise from either my athletics participation or any medical treatment I may receive. If any portion on this Release is held to be illegal, unenforceable, or in conflict with any laws of the State of Florida by any Court of competent jurisdiction, the remaining portions of this release shall not be affected. Signature of Participant USF ID Number of Birth Signature of Parent/Guardian if Participant is under 18 years of age

17 AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO INDIVIDUALS WITHIN AND ASSOCIATED WITH THE USF ATHLETIC DEPARTMENT This authorizes the athletic trainers, team physicians and athletics staff including coaches representing the University of South Florida to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information to the following INDIVIDUALS associated within and associated with the USF Athletic Department and for the following purposes: INDIVIDUALS: Student athletic trainers and other students who are participating in the provision of sports medicine healthcare. PURPOSE: to allow such student athletic trainers and other students participating in the delivery of sports medicine healthcare to assist and participate in the provision of healthcare to me while I am a student athlete. INDIVIDUALS: My teammates. PURPOSE: to advise them of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they will be aware of limitations that I may be under while I am a student athlete. INDIVIDUALS: My coaches, assistant coaches and other team related athletics staff. PURPOSE: to advise the coaches and athletics staff of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may make decisions regarding my athletic ability and suitability to compete while I am a student athlete. INDIVIDUALS: My Parents and/or Guardians. PURPOSE: to advise my parent/guardian of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may assist me in making healthcare decisions while I am a student athlete. This information that may be disclosed includes injuries or illnesses relevant to past, present or future participation in athletics at the University of South Florida. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations. I understand that the University of South Florida will not receive compensation for its use/disclosure of the information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization in writing at any time by notifying in writing the Assistant Athletic Director for Athletic Training, but if I do, it will not have any effect on actions the University of South Florida took in reliance on this authorization prior to receiving the revocation. This authorization expires six years from the date it is signed. Printed Name of Student-Athlete Sport of Birth Signature of Student-Athlete Signature of Parent/Legal Guardian (If Student-Athlete is under 18 years of age) I have reviewed the above statements but I do not wish to authorize this release. Initials

18 NOTICE OF PATIENT INFORMATION PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & Accountability Act of 1996 ( HIPAA ) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, to be kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, the University of South Florida has prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We participate in this notification, and will share protected health information (PHI), as necessary, to carry out treatment, payment, or healthcare operations. USES AND DISCLOSURES OF HEALTH INFORMATION The University of South Florida may use and disclose your protected health information for treatment, obtaining payment for treatment, and healthcare operations necessary to sustain our business. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be: o A physical examination or assessment. Payment means such activities as obtaining reimbursement for services, confirmation coverage, billing or collection activities and utilization review. An example of this would be: o We may provide information to your insurance company as needed to receive payment for services rendered to you. This may include, but is not limited to, diagnosis and treatment codes, treatment notes, and copies of documentation relevant to obtaining payment. Your insurance company, health plan, health insurance issuer or HMO with respect to a group health plan, may disclose protected health information to the sponsor of the plan. Healthcare Operations includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost -management analysis, and customer service. An example of this would be: o We may use your personal information to contact you to remind you of an upcoming appointment, either by phone or by mail. Some of the services we offer may be provided to you in a semi-private setting. For example, our Sports Medicine Clinic and Therapy Departments have an open gym area that allow athletic trainers and patients efficient access to equipment and modalities needed and shared by the department. The University of South Florida may use or disclose your protected health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. We may also create and distribute de-identified health information by removing all references to individually identifiable information. In any other situation, the University of South Florida s policy is to obtain your written authorization before disclosing your protected health information. An example of this would be a release to the media in regards to a specific injury or illness. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. The University of South Florida may change its policy at any time. This amendment will affect all protected health information maintained by the University of South Florida. When changes are made, a new Notice of Patient Information Practices will be posted in the training room areas that will display the Effective s and any Revision s, and will be provided to you on your next visit. You may also request an updated copy of our current Notice of Patient Information Practices at any time.

19 PATIENT S INDIVIDUAL RIGHTS You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: You have the right to review or obtain a copy of your protected health information at any time. You have the right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure of family member, other relatives, close personal friends or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. You may also request in writing that we not use or disclose your protected health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. The University of South Florida will consider all such requests on a case-by-case basis, but the practice is not legally required to accept them. You have the right to request that we amend your protected health information. You also have the right to request a list of instances where we have disclosed your protected health information for reasons other than treatment, payment or other related administrative purposes. You have the right to obtain a paper copy of this notice from us upon request. CONCERNS AND COMPLAINTS If you are concerned that the University of South Florida may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your protected health information, please contact our Privacy Officer or Quality Assurance Department at the address listed below. It is our intent to protect and keep your protected health information confidential. Your alerting us of any concerns you may have is a necessary part of a continuous quality process we employ. You will, in no way, be retaliated against for filing a complaint. You may also send a written complaint to the US Department of Health and Human Services. For further information on the University of South Florida s health information practices or if you have a complaint, please contact the following person: University of South Florida Sports Medicine Privacy Officer: Steve Walz M.A., ATC, LAT Assistant Athletic Director Director of Sports Medicine University of South Florida ATH 100 (813)

20 By signing this form I acknowledge that I have read and received the Notice of Patient Information Privacy Practices from the University of South Florida Sports Medicine Staff. I understand my rights as a patient and further understand that the University of South Florida Sports Medicine Staff may change their Notice of Privacy Practices at any time. If a change in this policy does occur, I understand that I will be notified in a timely manner. Student-Athlete Name (Print) Student-Athlete Signature Parent/Guardian Signature (if under 18 years of age)

21 MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION GUIDELINES Concussion Management The following are general guidelines based on the recommendations of the NCAA and National Athletic Trainers Association to be followed by all Certified Athletic Trainers when dealing with concussions: 1. Student-athletes will be provided educational material regarding concussions and will be required to sign a statement, at the time of or as close as possible to pre-participation examinations, in which the student-athlete accepts the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. 2. At the time of injury, the ATC should document all information pertinent to the concussive event including 1) mechanism of injury; 2) initial signs and symptoms; 3) state of consciousness; 4) findings on serial neurological testing (SCAT2 test). 3. The ATC should monitor vital signs and level of consciousness after a concussion until the athlete s condition improves. 4. An athlete with a concussion should be referred to a physician / emergency room on the day of injury if he or she lost consciousness, experienced amnesia lasting longer than 15 minutes, vomited, experiences increased symptoms or experiences persistent decreased sensory or motor function. 5. An athlete with a mild concussion who has an increase in the number of post concussion symptoms, or the symptoms worsen over time or the symptoms interfere with the athlete s daily activities should be referred to a physician. 6. An athlete should be disqualified from competition on the day of injury if he/she experiences concussion symptoms, loss of consciousness or amnesia. 7. The University of South Florida Sports Medicine Staff / Team Physician will establish guidelines for return to activity for athletes who sustain a concussion and/or continue to have symptoms following initial injury. 8. An athlete with a history of concussion should be treated more conservatively; the severity of the concussion may require the athlete to see a physician. 9. An athlete who is sent home with a mild concussion should be given instructions for home care. 10. An athlete who suffers a diagnosed concussion will only be eligible to return to play following direct consultation, evaluation and clearance from a University of South Florida Team Physician and/or his/her designee.

22 MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION GUIDELINES University of South Florida Sports Medicine personnel will evaluate mild traumatic brain injured / concussive student-athletes as follows- Baseline Testing- testing to be completed at the time of or as close to the student-athlete s pre-participation physical examination as possible. a) Concussion Assessment Tool- SCAT2 b) Neuropsychological Assessment ImPACT INJURY MANAGEMENT Time of Injurya) Mild Traumatic Brain Injury Initial Evaluation b) Post Concussion Symptom Scale c) SCAT2 test (if applicable and available) d) Physician Evaluation (if applicable and available) Note: Any student-athlete that serially exhibits signs/symptoms, or behaviors consistent with a concussive injury, including, but not limited to: 1) Loss of consciousness; 2) Confusion, as evidenced by disorientation to person, time, or place; inability to respond appropriately to questions; inability to process information correctly and/or respond appropriately to analytical questions; or inability to remember assignments and/or plays; 3) Amnesia (anterograde and/or retrograde; immediate or delayed); 4) Abnormal neurological examination (i.e. abnormal papillary response, persistent dizziness or vertigo, abnormal balance, etc.) 5) New and persistent headache, particularly if accompanied by photosensitivity or other visual disturbances, tinnitus, nausea, vomiting, or dizziness; and/or 6) Any other persistent signs or symptoms of a concussive injury should be withheld from participation for the remainder of that day. Once removed from participation, the student-athlete must follow the outlined guidelines for management of his/her injury and will not be considered for return to participation until he/she is fully asymptomatic at both rest and exertion, post-exertion assessments are within normal baseline limits, and he/she has been cleared for participation by the University of South Florida Team Physician and/or his/her designee.

23 MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION GUIDELINES Post- Concussion Follow-Up (24-hours post-injury)- a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale c) SCAT2 Test d) Neuropsychological Assessment ImPACT e) Physician evaluation and/or consultation Note- The Mild Traumatic Brain Injury Evaluation Form / Post Concussion Symptom Scale will be repeated every day until the student-athlete Self-Reports Asymptomatic (SRA), at which time the student-athlete will begin with Day 1 SRA Procedures. During the period of recovery and while the student-athlete is symptomatic following injury, the student-athlete should engage in physical AND cognitive rest until such time that he/she is asymptomatic. Post- Concussion Follow-Up (48-hours post-injury)- a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale c) SCAT2 Test d) Neuropsychological Assessment ImPACT e) Physician evaluation and/or consultation (as needed and/or warranted) Post- Concussion Follow-Up (7-days post-injury)- a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale c) SCAT2 Test Day 1 Self-Report Asymptomatic (SRA) a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale c) Neuropsychological Assessment ImPACT d) SCAT2 Test e) Cardiovascular exercise in controlled setting- (see sample protocol) Mode, duration and intensity dependant upon sport Monitor symptomology o If student-athlete becomes symptomatic, return the student-athlete to the concussed state / procedures until they Self-Report Aysmptomatic (SRA) Note- If the student-athlete develops any post-concussion symptoms during the Day 1 SRA Testing, the studentathlete should immediately stop all activity and rest for a minimum of 24 hours and until asymptomatic. After the minimum 24-hour rest period and once the student-athlete is asymptomatic, he/she should resume testing as per the Day 1 SRA Exertional Testing Protocol.

24 MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION GUIDELINES Day 2 Self-Report Asymptomatic (SRA)- a) Mild Traumatic Brain Injury Evaluation / Post Concussion Symptom Scale b) Sports-Specific Functional Activity Mode, duration and intensity dependant upon sport Note- If the student-athlete develops any post-concussion symptoms during the Day 2 SRA Testing, the studentathlete should immediately stop all activity and rest for a minimum of 24 hours and until asymptomatic. After the minimum 24-hour rest period and once the student-athlete is asymptomatic, he/she should resume testing as per the Day 1 SRA Exertional Testing Protocol. Day 3 Self-Report Asymptomatic (SRA)- a) Mild Traumatic Brain Injury Evaluation / Post Concussion Symptom Scale b) Supervised non-contact practice Note- If the student-athlete develops any post-concussion symptoms during the Day 3 SRA Testing, the studentathlete should immediately stop all activity and rest for a minimum of 24 hours and until asymptomatic. After the minimum 24-hour rest period and once the student-athlete is asymptomatic, he/she should resume testing as per the Day 2 SRA Exertional Testing Protocol. IF the student-athlete is asymptomatic with all activity on Day 3 SRA, consult with the Team Physician for return to play clearance. Day 4 Self-Report Asymptomatic (SRA)- a) Provided that the student-athlete has achieved a full resolution of symptoms, passed the functional progression without recurrence of symptoms and received clearance from a University of South Florida Team Physician and/or his/her designee, the athlete may return to full contact, unrestricted, supervised practice.

25 RETURN TO PLAY PROGRESSION Post-Concussion Exertional Testing Protocol Guidelines- Return To Play- In order to be considered for return to play, the student-athlete must- 1. Follow the outlined guidelines for management of his/her injury; 2. Be fully asymptomatic at rest, with exertional testing, and with supervised non-contact and contact sports-specific activities. 3. Be within normal baseline limits on all post-exertion assessments; and 4. Be cleared for participation by the University of South Florida Team Physician and/or his/her designee. All testing is to be done in a controlled setting and under the direct supervision of a certified athletic trainer. Monitor symptomology. If the student-athlete self-reports asymptomatic, proceed to the next level. If the student-athlete reports symptoms at any time. a. STOP THE TESTING PROTOCOL b. Rest for a minimum of 24 hours and until asymptomatic c. After the minimum 24 hour rest period and when asymptomatic, resume testing at the beginning of the last asymptomatic level. Exertional Testing Protocol- Level 1 (Sub-Maximal Cardiovascular Training)- [preferably indoors] Exercise elliptical trainer/ Stationary bike Duration- 15 minutes 65% maximal heart rate (220 age x.65 = target heart rate) Level 2 (Maximal Cardiovascular Training)- Exercise elliptical trainer/ Stationary bike Duration- 20 minutes 85% maximal heart rate (220 age x.85 = target heart rate) Level 3 (Sub Maximal Anaerobic Training) Sit-ups and/or crunches One (1) minute continuous exercise Level 4 (Maximal Effort Anaerobic Training)- 300 yard shuttle run Level 5 (Weight Training)- Mode, duration and intensity dependent upon sport If Day 2 does not fall within the student-athlete s scheduled weight lifting schedule, the student-athlete should still perform weight training exercises under the direction of a certified athletic trainer.

26 CONCUSSION MANAGEMENT PROTOCAL AGREEMENT I,, have been presented educational material regarding concussion injuries. I have read and understand this material and am aware of the concussion management protocol in place at the University of South Florida. I agree to report fully and honestly any and all concussion signs and/or symptoms I experience as a result of an injury, whether sustained during athletic participation or outside of athletic participation, to the University of South Florida Sports Medicine staff. I understand that withholding information regarding my symptoms puts me at risk for further injury and prevents the USF Sports Medicine staff from accurately assessing and managing my injury. I agree to abide by the USF Concussion Management Protocol and any treatment/management plans set forth by the USF Sports Medicine Department and/or USF Team Physicians. Signature of Participant USF ID Number of Birth Signature of Parent/Guardian if Participant is under 18 years of age

27 ADHD BANNED SUBSTANCE MANAGEMENT AND DOCUMENTATION The NCAA bans classes of drugs that can be harmful to student-athletes and that can create unfair advantages during competition (NCAA Bylaw ). Some medications that student-athletes are prescribed for legitimate medical reasons contain NCAA-banned substances. The NCAA, through the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. With respect to the use of banned medications used to treat Attention Deficit Hyperactivity Disorder (ADHA), Attention Deficit Disorder (ADD) and/or other medical conditions (Ritalin, Stattera, Adderall, Concerta etc.). The NCAA requires documentation of a comprehensive clinical evaluation to support treatment with NCAA banned medications and a current prescription. At a minimum, student athletes prescribed NCAA banned medications for the treatment of ADHD, ADD, and/or like conditions must provide the following documentation from the prescribing physician: 1. Evidence of comprehensive clinical evaluation (recording observations and results from standardized rating scales and/or neuropsychological testing) a physical exam and any lab work (attaching all documentation); A simple statement from a prescribing physician that he/she is treating the studentathlete for ADHD, ADD, and/or like conditions with the prescribed medication IS NOT adequate documentation. 2. Statement of diagnosis, including when diagnosis was confirmed 3. History of ADHA, ADD, and/or like conditions treatment (previous and ongoing) 4. Recommended treatment (attached current prescription) 5. Statement that a non-banned ADHD alternative has been considered and why banned stimulant was prescribed 6. Annual follow-up with prescribing physician and update letter or copy of medical record is required in each year of eligibility. The above documentation must be on file with the University of South Florida Sports Medicine Department in order for the student-athlete to participate in intercollegiate athletics at the University of South Florida. if you have specific questions regarding the NCAA Bylaws related to banned substances, drug testing, and/or medical exceptions can view the NCAA website (

28 ADHD BANNED SUBSTANCE I, affirm that I have been informed by the University of South Florida Sports Medicine Department about the NCAA Banned Substance List and NCAA Medical Exceptions Policy as it specifically pertains to the use of banned stimulant medications (Ritalin, Stattera, Adderall, Concerta, ect.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and/or like conditions. I attest that (initial (a) or (b) below): (a) I AM NOT presently taking and/or have taken within the last 12 months any banned medications (e.g. Ritalin, Stattera, Adderall, Concerta, ect.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD) and/or other medical conditions. I understand that I am to immediately notify a member of the USF Sports Medicine Staff should I ever be prescribed the aforementioned medications and that I must obtain and submit appropriate documentation to the USF Sports Medicine Department from the prescribing physician. (b) I AM presently taking and/or have taken within the last 12 months banned medications (e.g. Ritalin, Stattera, Adderall, Concerta, ect.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD) and/or other medical conditions. I understand that I must obtain and submit appropriate documentation to the USF Sports medicine Department from my prescribing physician. I have truthfully represented whether or not I am currently taking an NCAA Banned medication. If I am currently taking a NCAA banned medication or am prescribed one at a future date, I understand and agree that I will notify a member of USF Sports Medicine Staff and provide appropriate documentation in order for me to participate in intercollegiate athletics at the University of South Florida. Student-Athlete Signature Parent/Guardian if under the age of 18 years

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