1 Dear Parent/Student-Athlete: On behalf of the athletic training staff, we would like to welcome you back to MSUM Athletics. We would like to take this opportunity to remind you of some important information regarding our policies in dealing with athletic injuries. ALL STUDENT-ATHLETES ARE REQUIRED TO HAVE PERSONAL INSURANCE, EITHER THEIR OWN OR THROUGH THEIR PARENTS/GUARDIANS. The insurance MUST cover the student-athlete in Minnesota and North Dakota. MSUM ATHLETICS DOES NOT PROVIDE ANY PRIMARY OR SECONDARY ATHLETIC INSURANCE COVERAGE. The goal of MSUM s athletic training staff is to provide our student-athletes with the best possible medical care. MSUM Athletics is affiliated with Sanford Health, Fargo, ND. Student-athletes will be referred to team physicians provided by Sanford, unless their personal insurance dictates otherwise. If the student-athlete and/or parents wish to have a second opinion, that is encouraged. However, please keep in mind that the final authority for determining any student-athlete s return to play will be MSUM team physicians. Should a student-athlete incur a medical expense, the student s personal insurance will be billed. If there is an outstanding balance at that time, the student-athlete, and/or parents, will be responsible for the remaining balance. Please familiarize yourself with all requirements of the insurance policy that you carry. It is advisable to let your insurance company know that you have a dependent that will be traveling away from home so that you will be able to determine what will need to be done in the event that a claim must be filed. Please return this letter, as well as the following forms, to MSUM Athletic Training, no later than July 15, (ALL forms must be completed and on file in the athletic training room before any student-athlete is eligible for participation in any intercollegiate activity.) Physical Exam (5 th Year Seniors ONLY) Medical History Update Insurance information Copy of insurance card (front and back) Policies and Procedures ADHD form Informed and Medical Consent Second Party Information Release Concussion form Sickle Cell Trait Waiver (or test results) Substance Abuse Program Information MAIL/FAX/ ALL FORMS TO: Andrea Scott, MS, ATC Head Athletic Trainer Minnesota State University Moorhead th Ave. S. Moorhead, MN FAX Please sign this letter indicating that you have read and understand the information above, and send it with the other forms. Please feel free to contact us if you have any questions at or Student-Athlete Name: Sport: Please Print Full Name Student-Athlete Signature: Date:
2 Athletic Physical Examination (EXAMS MUST BE DONE BY A MEDICAL DOCTOR OR OSTEOPATHIC PHYSICIAN) PLEASE PRINT This form was developed in accordance with the NCAA Sports Medicine Guidelines and the AHA Recommendation for Cardiovascular Preparticipation Screening of Competitive Athletes Name Date of Exam Date of Birth Age Sex Sport Height (inches) Weight (lbs.) Brachial Blood Pressure (sitting position) Pulse Vision Right 20/ Left 20/ Hearing (Whispered voice at 10 feet) Contact Lens: Yes No Color Blind: Yes No Right: Normal Abnormal Left: Normal Abnormal Clinical Evaluation Normal Abnormal NOTES (Describe any abnormality in detail. Include results of any lab done.) 1. Scalp, Face, Neck, Thyroid 2. Nose and Sinuses 3. Mouth (tongue, gingivae, teeth) 4. Throat and Tonsils 5. Ears (tims and ext. canals) 6. Eyes (pupils, EOM conjunct.) 7. Lungs and Chest (include breasts) 8. Heart (rhythm, sounds, murmurs) a. Precordial auscultation (supine) (standing) b. Assessment of femoral artery pulses (to exclude coarctation of the aorta) c. Physical stigmata of Marfan syndrome 9. Sickle Cell Trait 10. Abdomen and Viscera 11. Hernia 12. Anus and Rectum (prostate if indicated) 13. Endocrine system 14. G-U System 15. Upper Extremity (shoulder, arm, wrist, hand) 16. Lower Extremity (hip, thigh, knee, ankle, foot) 17. Skin, Lymphatic Glands (cervical, inguinal, axillary) 18. Neurologic 19. Pelvic (if deemed necessary) Menstrual Cycle 20. Surgery(ies) 21. Other Drug Allergies, Medications currently prescribed, etc. (Over) Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System.
3 Physician Recommendation Please Complete 1. Approved for athletic participation without limitation. 2. Approved for athletic participation with limitation. Specify: 3. NOT approved for athletic participation. Specify: Printed Name of Physician: Clinic Name/Facility: Street/City/State/Zip: Phone: Fax: Signature of Physician: Date Medical License #: This form must be signed by an MD or DO.
4 Returning Athlete s Medical History Update Complete the information below ONLY if you competed or participated on an MSUM intercollegiate athletic team during this past school year. Please Print Date: Name: Sport: 1. Have you had any health-related problems or seen a medical doctor since LAST MAY? q Yes q No If yes, when and for what reason? 2. Do you take any medication(s) regularly or for emergency use? q Yes q No If yes, please list the medication(s), why you take them (i.e., diabetes, asthma, bee sting, allergies), and dosage. 3. List any other medical conditions or allergies that you may have developed since last LAST MAY? 4. Review of systems: Please check if you have developed any problems with any of the following areas of your body since last LAST MAY: q Skin q Head q Lungs q Hips, knees, legs, feet q Eyes q Heart q Muscles/Tendons q Ears q Abdomen q Depression/Anxiety q Nose q Back q Other: what? q Mouth/throat q Bowel/Bladder q Nutrition/weight control q Genital (including menstrual for females) q Neck q Shoulders, elbows, hands, fingers Explain I have answered truthfully all questions and understand that withholding any history of prior illness/injury may release Minnesota State University Moorhead from any financial responsibility or legal liability for a preexisitng problem. Athlete s Printed Full Name Date Athlete s Full Signature Minnesota State University Moorhead is an equal opportunity educator and employer and is a member of the Minnesota State Colleges and Universities System. This information will be made available in alternate format upon request by contacting Disability Services at (voice) or (MRS/TTY).
5 Athletic Insurance Information Sheet PLEASE RETURN TO ATHLETIC TRAINING ROOM The following information and authorization must be completed, signed, and returned before the athlete will be allowed to participate! Athlete s Full Name Permanent Address (City/State/Zip) Sport Birthdate Phone ( ) PRIMARY INSURANCE: Policy Holder Relationship Policy Holder s Date of Birth Policy Holder s Home Address Home Telephone Number ( ) Cell Number ( ) Policy Holder s Employer s Name Employer s Address Name of Insurance Company Insurance Mailing Address ID Number Group Number Insurance Company Telephone Number ( ) Is your dependent son/daughter covered under the above policy? q Yes q No. Does your insurance require: a second opinion for surgery? q Yes q No Pre-authorization for service? q Yes q No SECONDARY INSURANCE: Policy Holder Relationship Policy Holder s Date of Birth Policy Holder s Home Address Home Telephone Number ( ) Cell Number ( ) Policy Holder s Employer s Name Employer s Address Name of Insurance Company Insurance Mailing Address ID Number Group Number Insurance Company Telephone Number ( ) Is your dependent son/daughter covered under the above policy? q Yes q No. Does your insurance require: a second opinion for surgery? q Yes q No Pre-authorization for service? q Yes q No Please indicate which of the following medical facilities in the Fargo-Moorhead area your insurance company will allow you to use. If your insurance company allows you to receive services anywhere, Sanford Clinics and Hospital will be used since our Team Physicians are affiliated with Sanford. PLEASE CHECK ALL THAT APPLY: q My insurance allows for services ANYWHERE in the Fargo/Moorhead area q My insurance allows for EMERGENCY services ONLY in the Fargo/Moorhead area q Sanford Hospital q Sanford Clinics q Essentia Health q Fargo-Moorhead Area Independent Physician (Please list below) Name/Clinic (Over)
6 Please Note: You may want to consider transferring your medical insurance coverage to the Fargo/Moorhead area while you are participating in intercollegiate athletics. If you are from out-of-town, many HMO s or PPO s will only cover medical expenses within your local region. This often becomes inconvenient for the student-athlete when he/she has to travel to hometown hospitals or clinics. Authorization, Agreement, Consent, Release and Indemnification I hereby authorize Minnesota State University Moorhead to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays and/or any other data covering this and/or previous confinements and/or disabilities. I understand the risks of injuries and losses that can occur as a result of participating in intercollegiate athletic activities and assume all such risks. I hereby allow Minnesota State University Moorhead s Athletic Medical Staff to administer whatever medical treatment and/or care deemed necessary for the health and well-being of myself. Furthermore, I consent to have administered to me any emergency medical or surgical treatment recommended by any licensed physician In consideration of the student athlete being permitted to participate in Minnesota State University Moorhead s Intercollegiate Athletic Program. I release and agree to idemnify and hold harmless Minnesota State University Moorhead, its Board, president, officers and employees against and from any and all claims, damages and expenses arising out of or resulting from such injuries, losses and medical treatment or care. A photostatic copy of this authorization shall be deemed as effective and valid as the original. I understand that if my insurance lapses during the school year, or athletic season(s), that I am responsible for any and all bills related to athletic injuries occurring during that time. Date: Signature of Custodial Parent/Legal Guardian (if athlete is under 18 years of age) Date: Signature of Student-Athlete Please submit a photocopy of your insurance card to accompany this form. We must have copies of BOTH sides of the card. You will not be allowed to participate without a copy of your card on file! Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System.
7 MINNESOTA STATE UNIVERSITY MOORHEAD ATHLETIC TRAINING MEDICAL PROCEDURES I. Mandatory Physical Examinations: A. Every new student-athlete must have a physician-approved physical examination on file with the athletic training department prior to any participation in conditioning, practice, or game. Student-athletes must have a new physical exam done every four years. If you participated at MSU Moorhead in athletics, and then sat out one or more semesters, you must have an updated physical examination. B. Student-athletes must complete the athletic medical forms and submit them to Andrea Scott, Head Athletic Trainer, Minnesota State University Moorhead, Moorhead, MN II. Reporting Injuries: A. Report all injuries, cuts, abrasions, etc., immediately after participation. Infections can be held to a minimum by early treatment. If you are injured during participation, contact the athletic trainer immediately. The athletic trainer will take whatever steps are necessary. B. The head coach will be notified of the student-athlete's injury or illness. C. As members of an MSUM athletic team it is the responsibility of the student-athlete to report to the athletic training room for injury evaluation, treatment, and rehabilitation. If further referral is needed, the athletic training staff will give assistance. III. Evaluating Injuries: A. Injured student-athletes will be evaluated immediately by an athletic trainer or athletic training student. B. The student-athlete may be referred to the athletic training room for treatment, to a physician or to Hendrix Clinic and Counseling Center for additional evaluation. (also see V.B) C. If the student-athlete needs to see a physician, the athletic trainer will make the necessary arrangements. D. After approval by the team physician and/or a certified athletic trainer, the studentathlete will return to practice and/or competition. MSUM team physicians have final approval on whether a student-athlete is cleared for participation. E. The head coach will be notified of all injuries/illnesses pertaining to his/her respective student-athletes. IV. Illness: A. In case of illness, contact the athletic trainer prior to noon of each day. B. The Hendrix Clinic and Counseling Center is open 8:00am-4:30pm Monday through Friday during fall and spring semesters. Any student who has paid activity fees is eligible to use Hendrix Clinic and Counseling Center. (There is no charge to see a doctor.) If referred to a physician or to Hendrix Clinic and Counseling Center by an athletic trainer, the athlete must have an Athletic Medical Referral Form. This form is to be completed by the attending physician and/or a nurse practitioner, and returned to the athletic trainer before athletic participation can be resumed. C. Any medication(s) prescribed by a physician is/are at the expense of the studentathlete...not THE MSUM ATHLETIC DEPARTMENT!
8 V. Medical Expenses: A. MSUMDOES NOT provide any primary or secondary athletic insurance. All studentathletes must be insured, either under their parents/guardians or a personal insurance policy. All expenses related to athletic injuries will be billed to the student-athletes insurance. Any bills not covered by insurance will be the responsibility of the studentathlete and/or parents/guardians. 2 B. If a student-athlete desires to seek medical care/treatment other than through the MSUM athletic medical staff, he/she must be cleared by the athletic training staff prior to receiving the care and treatment. This is to insure that the necessary insurance paperwork and injury reports are completed BEFORE the appointment(s) so appropriate care is provided once a diagnosis is received. ATHLETIC TRAINING ROOM RULES 1. The athletic training room is open Monday through Friday from 1:00 to 6:00pm. Morning hours are by appointment only. 2. All treatments, taping, medications, and consultations given after practice are done AFTER SHOWERING. 3. No shoes will be allowed in the athletic training room area. 4. Athletic equipment (football pads, cleats, spikes, etc.) is to be kept out of the athletic training room. 5. Athletic training towels are to remain in the athletic training room. Towels are not to be used for any purpose other than treatments. 6. Supplies/equipment will be dispensed/operated by athletic training staff only. 7. This is the MEDICAL CENTER for MSUM Athletics. Horseplay, profanity, use of tobacco, food, and drinks are not allowed while receiving treatments. 8. The athletic training room is co-ed. Shorts and t-shirts are required. 9. In-season, injured student-athletes have priority in receiving treatments. The athletic training staff reserves the right to schedule treatment times. 10. Athletes injured and unable to practice should check with the athletic trainers daily for prescribed activities/rehab. 12. Give respect, receive respect, and respect the athletic training staff. EMERGENCY TELEPHONE NUMBERS Hendrix Clinic and Counseling Center Sanford Health Medical Center Emergency Room MSUM Athletic Training Room Office or (Andy, Ronda, Keith, Chuck) Head Athletic Trainer Andrea Scott (C) Assistant Athletic Trainer Ronda Peterson (C) Assistant Athletic Trainer Keith Wiedrich (C) Assistant Athletic Trainer Charlie Meek (C) Assistant Athletic Trainer Erin Heine (C) Assistant Athletic Trainer Eric Lundberg (C) 2
9 PLEASE KEEP THE ATHLETIC TRAINING MEDICAL PROCEDURES AND ATHLETIC TRAINING ROOM RULES FOR FUTURE REFERENCE WHILE AT MSU MOORHEAD 3 MINNESOTA STATE UNIVERSITY MOORHEAD Athletic Training Medical Procedures and Athletic Training Room Rules Signature Form I have received, read, and fully understand the Minnesota State University Moorhead Athletic Training Medical Procedures and Athletic Training Room Rules, and will comply with them. PLEASE PRINT ATHLETE'S FULL NAME: (first) (middle) (last) SIGNATURE: (full name) SPORT: DATE: IF STUDENT-ATHLETE IS UNDER 18 YEARS OF AGE Parent/Guardian Signature is Required PARENT'S/GUARDIAN'S SIGNATURE: DATE: (revised 4/15) 2
10 Minnesota State University Moorhead Information Regarding the Use of Banned Stimulants for Treatment of ADHD, ADD and/or like conditions. Background The NCAA bans classes of drugs that can be harmful to student- athletes and that can create unfair advantages during completion (NCAA Bylaw ). Some medications that student- athletes are prescribed for legitimate medical reason contain NCAA banned substances. Effective August 1 st, 2009, with respect to the use of banned stimulant medication used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and/or like conditions, (e.g. Ritalin, Strattera, Adderall, Concerta, etc.) the NCAA now requires documentation of a compressive clinical evaluation to support treatment with NCAA banned stimulants and a current prescription. Who to contact if prescribed stimulant medications for ADHD, ADD, and/or like conditions. Student- athletes who have been prescribed stimulant medications for the treatment of ADHD, ADD, and/or like conditions should immediately notify a member of the athletic training department to ensure that they have the necessary documentation on file. What documentation must the student- athletes obtain from his/her prescribing physician? At a minimum, student- athletes prescribed NCAA banned stimulants 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 student- athlete for ADHD, ADD, and/or like conditions with the prescribed stimulant IS NOT adequate documentation. 2. Statement of diagnosis, including when diagnosis was confirmed. 3. History of ADHD, ADD, and/or like conditions treatment (previous and ongoing). 4. Recommended treatment (attaching 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 updated letter of copy of medical record is required in each year of eligibility. When and where should documentation be sent? Andrea Scott Minnesota State University Moorhead th Ave S. Moorhead, MN If your son/daughter s physician needs a sample evaluation form or more detail on the information needed for the documentation, please feel free to contact me. Also, if you have any other questions please do not hesitate to me. Andrea Scott, MS, ATC Phone:
11 Minnesota State University Moorhead ADHD Medical Exceptions Notification Form I, affirm that I have been informed by Minnesota State University Student- Athlete Print Name Moorhead athletic training personnel on this date, about NCAA Banned Substances List and NCAA Medical Exceptions Policy as it specifically pertains to the use of banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and or/like conditions. I attest that: Initial Initial I AM NOT presently taking and/or have taken within the last 12 months any banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.), that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), or like conditions. I AM presently taking and/or have taken within the last 12 months banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.), that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), or like conditions. I, the undersigned, do hereby affirm that I understand that I am to immediately notify a member of the Minnesota State University Moorhead athletic training department should I ever be prescribed the aforementioned stimulant medications and that I must obtain and submit appropriate documentation from the prescribing physician. I further attest that I have had any and all questions regarding the NCAA ADHD Medical Exceptions Policy answered to my satisfaction. Student- Athlete Signature Date Student- Athlete Print Name Athletic Trainer Print Name Date
12 TO ALL ATHLETIC TRAINERS AND MEDICAL PERSONNEL Athletic Training SECOND PARTY INFORMATION RELEASE AUTHORIZATION on the Minnesota State University Moorhead staff, including full-time, part-time, and consultants: You are authorized to provide to my parents or guardians and to scouts, coaches, the media, University personnel and medical personnel, information concerning my health care, injury, rehabilitation, treatment, and health status. This information is to be used for the purpose of advising persons of my health or injury status. You are also authorized to obtain medical information and records from all of my past or present health care/medical treatment providers. This authorization is valid while I am a student at Minnesota State University Moorhead. A photographic copy of this authorization is valid as the original. Date: Signature Printed or Typed name Birthdate If you are under the age of 18 a parent or guardian must sign this form: Date: Signature of Parent or Legal Guardian Printed or Typed name Address of Parent or Legal Guardian Address of Parent or Legal Guardian Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System. This information will be made available in alternate format, such as Braille, large print or audio cassette tape, upon request by contacting Disability Services at (voice) or (MRS/TTY).
13 Athletic Training Informed and Medical Consent Form Please read, sign and return to us the following consent form. If you are under 18 years of age, your parents/guardians must also sign. If you should choose to refuse to sign this consent form, please write Refused to sign, the date, and your signature on the appropriate line. Informed and Medical Consent I, (print name), am aware that trying out, practicing, or playing in any sport can be a dangerous activity involving many risks or injury. I understand that the dangers and risks include, but are not limited to, death, serious head, neck and spinal injuries, paralysis, injuries or impairment to the musculoskeletal system, or other aspects of the body, general health, and well-being. Because of the dangers of participating in sports, I recognize the importance of following the instructions of the athletic department personnel regarding playing techniques, training, rules of the team/sport, equipment, and to obey such rules. I also acknowledge that some sports are classified as collision sports involving even a greater risk of injury than other sports. I further realize that I am expected to report all injuries/illnesses I may have sustained during periods of official, organized athletic participation (including all regularly scheduled practices and contests) and throughout the calender year, (regardless of how they occurred) to a coach, to an athletic trainer, or to a team physician. I hereby grant permission to the Minnesota State University Moorhead Team Physicians and/or their consulting physicians to render to myself (son/daughter) any treatment, medical or emergency surgical care that they deem reasonably necessary to the health and well-being of the student-athlete. I also hereby authorize the Minnesota State University Moorhead Athletic Trainers, and their staff, who are under the direction and guidance of the Minnesota State University Moorhead Team Physicians, to render to myself (son/daughter) any preventive measures for injuries, first aid, treatment, rehabilitation, or emergency treatment that they deem reasonable and necessary to the health and well-being of the student-athlete. This includes all practices, games, and travel. When necessary for executing such case, I grant permission for hospitalization at an accredited hospital. (Signature may be that of the student-athlete over 18 years of age; if under 18 this form must also be signed by a parent or guardian.) Date Signature of Athlete Printed or Typed Name Signature of Parent or Legal Guardian Printed or Typed Name Address of Parent or Legal Guardian Address of Parent or Legal Guardian Date
14 CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A CONCUSSION? A concussion is a brain injury that: Is caused by a blow to the head or body -From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Can change the way your brain normally works. Can range from mild to severe. Presents itself differently for each athlete. Can occur during practice or competition in ANY sport. Can happen even if you do not lose consciousness. HOW CAN I PREVENT A CONCUSSION? Basic steps you can take to protect yourself from concussion: Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking unprotected opponent, and sticks to the head all cause concussions. Follow your athletic department s rules for safety and the rules of the sport. Practice good sportsmanship at all times. Practice and perfect the skills of the sport. WHAT ARE THE SYMPTOMS OF A CONCUSSION? You can t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: Amnesia. Confusion. Headache. Loss of consciousness. Balance problems or dizziness. Double or fuzzy vision. Sensitivity to light or noise. Nausea (feeling that you may vomit). Feeling sluggish, foggy or groggy. Feeling unusually irritable. Concentration or memory problems (forgetting game plays, facts, meeting times). Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? Don t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep, and classroom performance. Take time to recover. If you have a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. I understand that I am responsible for reporting all injuries and illnesses to the MSUM Athletic Training staff, including the signs and symptoms of concussions, and I acknowledge that the MSUM Athletic Training staff has educated me on concussions. Student-Athlete Signature Parent/Guardian Signature (if athlete is younger than 18 years of age) Date Date
15 Sickle Cell Trait Waiver NCAA regulations now recommend that all incoming student-athletes be tested for sickle cell trait. Results from a previous test or a signed waiver are alternatives to testing. However, test results or a signed waiver MUST be turned in to the athletic training department before student-athletes will be allowed to participate in any athletic activity. Please read the information below and speak to your health-care provider to determine if you are at risk of having sickle cell trait. What is sickle cell trait? Sickle cell trait is not a disease. Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Sickle cell trait will not turn into the disease. Sickle cell trait is a life-long condition that will not change over time. During intense exercise, red blood cells containing the sickle hemoglobin can change shape from round to quarter moon, or sickle. Sickle red cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to the tissues and muscles. During intense exercise, athletes with sickle cell trait have experienced significant physical distress, collapsed and even died. Heat, dehydration, altitude and asthma can increase the risk for and worsen complications associated with sickle cell trait, even when exercise is not intense. Signs of sickling include fatigue, difficulty breathing, leg or low back pain, and sudden weakness. Athletes with sickle cell trait should not be excluded from participation as precautions can be put into place. Who is at risk for sickle cell trait? Although sickle cell trait is most predominant for those whose ancestors come from Africa, South or Central America, India, Saudi Arabia and Caribbean and Mediterranean countries, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait occurs in about 8 percent of the U.S. African American population, and between one in 2,000 and one in 10,000 in the Caucasian population. Most U.S. states test at birth, but most athletes with sickle cell trait don t know they have it. Please contact MSUM Athletic Training at if you have any questions. I, understand that NCAA regulations recommend that all incoming student-athletes be tested for sickle cell trait. For, and in consideration, of my being allowed to participate in college athletics at Minnesota State University Moorhead, I accept any and all risks of harm that may result from this voluntary decision. I further release, hold harmless and agree to indemnify the State of Minnesota, Minnesota State University Moorhead, and/or their respective employees from any and all liability for claims stemming from this decision, including but not limited to, any and all risk of injury, sickness, disease or any other harm, and I further certify that I will not seek compensation or legal relief in the event I suffer illness or injuries due to my decision not to be tested for sickle cell trait. I further certify that I am of legal age (18 years or older) and am under no legal disability that would interfere with my ability to knowingly sign and execute this consent and waiver form. Student-Athlete Signature Date Parent/Guardian Signature (if under 18 years of age) Date
16 MINNESOTA STATE UNIVERSITY MOORHEAD ATHLETICS SUBSTANCE ABUSE PROGRAM A. INTRODUCTION: As an institution of higher learning, Minnesota State University Moorhead has committed itself to enriching the lives of its students through both classroom activities and campus cultural programs. It is hoped that these experiences will enhance the development of responsible behavior in students academic lives and their social activities. It is evident that the abuse of alcohol or any other drugs will always minimize student s abilities to develop academic potential or social relationships. According to Minnesota State University Moorhead s Substance Use and Abuse Policy in the Student Handbook, alcoholic beverage and drugs are not permitted on the campus of Minnesota State University Moorhead. The unlawful use, possession or distribution of alcoholic beverages or illegal drugs at University sponsored events, on- or off-campus, is prohibited by federal and/or Minnesota State Law (Section 340A). The following is an outline of the drug screening and testing guidelines for the duration of the studentathlete s eligibility at Minnesota State University Moorhead. The student is expected to cooperate in the administration of this policy and its guidelines. Refusal to cooperate will result in suspension from participation in athletically-related activities; therefore, discontinuance of any athletically-related financial aid at the beginning of the next semester. The policy applies to all male and female intercollegiate varsity and junior varsity team members, cheer team, athletic student trainers and student managers. B. PURPOSE: 1. To establish and provide an informative program to help educate student-athletes on the potentially adverse affects of chemical substances. The program will involve representatives of the health care profession known to be qualified in the areas of drug usage and abuse. 2. To utilize reputable testing methods proven effective in the identification of persons who abuse the use of chemical substances. 3. To establish an eligibility policy for student-athletes who do not comply or who do test positive. 4. To identify and provide a channel of education, counseling, and rehabilitation for the studentathlete with a chemical abuse or dependency problem. C. IMPLEMENTATION: During the academic year, a presentation will be made to each sport by the Head Coach or Athletic Trainer outlining the University s Substance Abuse Program. A copy of the policy will be given to each student-athlete. Each athlete will be asked to: 1. Sign a statement acknowledging receipt of a copy of the policy. 2. Execute involuntary consent to the screening/testing required by the program. 3. Sign a statement authorizing release of results to: Director of Athletics/Head Coach/Head Athletic Trainer, Hendrix Health Center Director (HHCD), Chemical Health Educator/Licensed Addiction Counselor (CHE/LAC). 1
17 D. EDUCATIONAL REQUIREMENT: The NCAA requires that all student-athletes complete a minimum alcohol and drug education program. At MSUM, that requirement will be fulfilled by attending several different meetings, presentations, and possibly an on-line educational program. E. SCREENING AND ASSESSMENT: All athletes will participate in a substance abuse screening program coordinated by the Head Athletic Trainer and Hendrix Health and Counseling Director and HHC Lab. This will include but not be limited to written, computerized or verbal assessment. Failure to comply with established screening policy would mean loss of eligibility to practice or participate in their respective sport. PROCEDURE: Athletic Coaches will meet with their respective teams early in their seasons to review the Minnesota State University Moorhead Athletics Substance Abuse Program. This must be reviewed prior to the athletes attending the seminar and completing the screening test. Studentathletes are required to attend one educational seminar and complete the written screening test. F. REFERRAL: Athletes unable to attend the seminar and screening sessions established will be required to make an appointment with the Head Athletic Trainer to have screening completed. The Head Athletic Trainer will provide the HHCD with a current team roster of freshmen and transfer student athletes. The CHE/LAC will 1) verify that each athlete on the roster has completed screening and 2) notify each of those athletes failing to complete screening and of those in need of follow-up appointments. Results of the screening will be reviewed by the CHE/LAC. Those athletes whose screening indicate that they are at high risk for problems related to their substance use will be required to make an appointment with the CHE/LAC for further review and assistance. (The contents of these sessions are confidential between the athlete and the CHE/LAC). Students who demonstrate signs of problems with substance use will be referred to the CHE/LAC. Indicators which may be used in the evaluation of a students behavior include: class attendance record, significant GPA changes, practice attendance record, performance and health changes, motivation level regarding academic and athletic activity, emotional condition, mood swings, legal involvement, and extreme misconduct involving substance abuse or alcohol consumption. The Director of Athletics, Head Coach, Head Athletic Trainer or CHE/LAC can require student-athletes to report to the Hendrix Health and Counseling Center for assessment and possible testing. 2
18 G. TESTING: Minnesota State University Moorhead reserves the right to administer laboratory tests according to the following guidelines. The HHCD will be responsible for the supervision of all testing. Evidence for the following substances may be tested: amphetamines, barbiturates, benzodiazepines, opiates, cocaine, THC, PCP, LSD, alcohol and anabolic steroids. Athletes taking medication under a doctor s guidance will be given special consideration. Cases of this type should be brought to the attention of the HHCD. 1. PROCEDURE: Student-athletes may be referred for unannounced testing should those previously stated behavior indicators be identified by the Director of Athletics, Head Coach, Head Athletic Trainer, or CHE/LAC for probable cause. Student-athletes will be asked to sign an Informed Consent waiver giving Hendrix Health Center (HHC) permission to test upon referral or at announced times during the year. Under the supervision of the HHCD urine samples will be collected for analysis by the HHC Lab who will send sample to reference lab for screening. Samples will be tested first by Immunoassay Screening, and, if necessary, further tested utilizing Gas Chromatography/Mass Spectometry. Identification of those participating in the urinalysis, and the results will be strictly confidential. The testing service will notify the HHCD of all results. 2. COLLECTION PROTOCOL: a. Identification labels are made in duplicate by HHC. b. Team roster identifying persons submitting to drug screening is supplied by the athletic department and taken to HHC. c. Urine collection bottles are supplied by HHC. d. The collection must be an observed catch by a member of the HHC or Athletics staff. e. Collection of specimens obtained in a bathroom at HHC. f. Athlete deposits specimen in container and caps container. g. Athlete removes two labels containing same number, places one label on container, and the other by corresponding name on roster. h. Container and identification number are placed in plastic bag and sealed. 3. IDENTIFICATION AND SHIPMENT PROTOCOL a. Sealed containers are placed in shipment box by HHCD to be stored in refrigeration before courier from testing agency picks up shipment. b. Shipment is picked up by courier and transported to testing lab. c. Results are sent by courier to HHC Director and HHC Lab. d. HHC Director and HHC Lab matches test results with identification. e. HHC Director sends letters to all tested athletes and respective coach, Head Athletic Trainer, and Director of Athletics. f. Upon positive test results, athletes are requested to contact CHE/LAC for individual appointment (or whatever is decided). g. Upon failure of athlete to contact CHE/LAC within one week, HHCD will notify appropriate Head Coach, Head Athletic Trainer, and the Director of Athletics that athlete has failed to comply with the testing program. 3
19 4. RESULTS All student-athletes tested will be notified of his/her test results in a letter from the HHCD. The appropriate Head Coach, Head Athletic Trainer and Director of Athletics will also be notified. PHASE I: If a student-athlete tests positive, and Substance Abuse Appeals Committee (SAAC, comprised of a licensed physician, the CHE/LAC, HHCD and the Head Athletic Trainer) will immediately decide if it is safe for the student-athlete to participate in practice or competition. In addition, the student-athlete will be required to 1) submit to a follow-up urinalysis, the time to be determined by SAAC, 2) make an appointment with the SEC for further assessment and counseling, and 3) make an appointment with their head coach. PHASE II: Student-athletes testing positive a second time will be notified by letter. The studentathlete will be directed by the CHE/LAC to an appropriate drug education class and/or chemical dependency evaluation facility at the student s expense. The student may not participate in practice and competition until testing negative, complying with the recommendations of the CHE/LAC and receiving approval from SAAC. PHASE III: In the event a student-athlete again tests positive, he/she remains ineligible, pending successful completion of the requirements of Phase II. That student-athlete will be subject to random urine screening at his/her expense. H. ELIGIBILITY: 1. The athlete s eligibility requirements are those specified by the NCAA, NSIC, the Head Coach of his/her sport, and the Head Athletic Trainer 2. The athlete will be required to participate in the Substance Abuse Program as defined by University policy. 3. Failure to comply with any of the above requirements may deem an athlete ineligible for participation. I. REINSTATEMENT/APPEALS: A student-athlete who has been suspended from athletic participation may petition the Substance Abuse Appeals Committee. SAAC is made up of a licensed physician, the CHE/LAC, HHCD, and the Head Athletic Trainer. Reinstatement of the student-athlete to participate in athletics may be made only after they provide satisfactory proof of the successful completion of a certified rehabilitation program and proof that their system is tested clear of drugs. 4
20 Consent to Participate in MSUM Intercollegiate Athletics Substance Abuse Program To: Hendrix Health and Counseling Center Director Chemical Health Educator/Licensed Addiction Counselor I, hereby acknowledge that I have received a copy of the MSUM Athletics Substance Abuse Program. I further acknowledge that I have read the Policy, that it has been outlined to me, and that I fully understand the provisions of the Policy. I hereby voluntarily and without threat, inducement or compulsion, consent to have a sample of urine collected and tested for the presence of certain drugs or substances in accordance within the Substance Abuse Program, at such times as required under that program. I further authorize you to make a confidential release to my Head Coach and the Athletic Director, where appropriate under the Substance Abuse Program, or screening/testing results and/or of any failure on my part to comply with the requirements of the Substance Abuse Program. I understand that the screening laboratory shall release the results of the urinalysis to the HHC Director. I hereby release the Minnesota State Colleges and University System, Minnesota State University Moorhead, its employees and agents from legal responsibility or liability for the disclosure or release of any information from the records or forms kept pursuant to this policy. (Student s Full Name PRINTED) (Date) (Student s Full Signature) (Date) (Co-signature of Parent or Guardian if student is under 18 years of age) 5