CHECKLISTS OF ATHLETIC TRAINING INFORMATION

Transcription

1 CHECKLISTS OF ATHLETIC TRAINING INFORMATION Returning GCU Student Athletes: Until these forms are complete and you have been released to practice by the Athletic Training Staff, you will not be permitted to practice. There are NO exceptions to this requirement. Listed below are the forms as well as instructions on how to correctly complete each form. Please check that all have been included. 1. HEALTH REPORT: Complete the front side; include your primary insurance information. Must also include legible copy of both front and back of primary insurance card. 2. RETURNER ANNUAL HEALTH REVIEW QUESTIONAIRE: Complete this form entirely. For every box you have marked with a YES answer, please include an explanation in the space provided, and list year of injury or illness. Remember to sign your name at the bottom. The ATC at GCU will screen the form and sign it in the provided spaces. 3. HEAT ACCLIMATION QUESTIONAIRE: The purpose of this form is to help the athletic training staff determine if you are at risk for heat illnesses. Please read and answer all questions. 4. PRIMARY INSURANCE CARD: Please be sure to include a legible copy of both the front and back of the card. The card is needed in case of an emergency situation or to set up appointments with the team physicians.************don T FORGET THIS ONE!!! 5. STUDENT-ATHLETE ACKNOWLEDGEMENT AND CONSENT INFORMATION: Please read the information for each of these specific areas. Print out the last page (signature page), sign and return. ACKNOWLEDGEMENT OF RISK: CONSENT TO TREAT AND TRANSPORT: In case of severe accidental injury where you are unable to give verbal consent this allows us to treat and transport you. CONSENT TO RELEASE MEDICAL INFORMATION: Information for athletic injury insurance purposes so that we may contact your parents if they are the primary insurance carrier, physicians, and other health care personnel to inform them of the procedure that will expedite the medial and insurance process. AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION: This allows disclosure of health information that will be used only by the NCAA s Injury Surveillance System (ISS) for the purpose of conducting research on injuries resulting from training for or participation in athletics. Acknowledgment of GCU Secondary Insurance Policy: Designed to help athletes better understand the filing procedures of injury insurance claims. It also explains their responsibility in this process. MINORS: If you are not yet 18 years of age, please be sure that your parent/guardian also reads all information and includes their signature on the signature page. If you have any questions or comments, please feel free to contact the athletic training room staff at Thank you for your help and cooperation in this matter.

2 Please Print Grand Canyon University Student Athlete Health Report Name Date Last First Middle Sport Male Female Birthdate / / Age Social Security # Marital Status Married Single Year in School Local Address (while attending GCU) Local Phone # (while attending GCU) Mobile # Work Phone # Permanent (Home) Address Father s Name Work Phone # Address Home Phone # Mother s Name Work Phone # Address Home Phone # EMERGENCY INFORMATION Allergies: Medical Conditions: Medication Currently Taking (including birth control pills); In case of Emergency tify: Relationship: Address City, State, Zip Home Phone # Work phone # Mobile phone # ATHLETIC INSURANCE PROFILE Personal Insurance Carrier Insurance Carrier Address Insurance Claims Phone Number Member/ID Number Group Number Policy Owner s Full Name Employer Policy Owner s Social Security # Policy Owner s DOB Policy Owner s Address Does your personal insurance carrier require you to go to certain doctors and/or hospitals? If yes, please specify

3 RETURNER ANNUAL HEALTH REVIEW QUESTIONAIRE Print Name: SS# Sport: Date of Birth: Year in School Date of 1 st Medical Examination at GCU? Please complete and explain: Question Circle Explain 1. Have you participated in regular training during the off season? 2. Has anything occurred to prevent you from regular training during off season? 3. Do you currently have any incompletely healed injuries? 4. Are you currently ill in any way? 5. Are you taking any medication on a regular or continuing basis? 6. Have you experienced any dizziness, chest pain, shortness of breath or recurrent cough with exercise? 7. Have you had a significant change in weight since your last physical? 8. Have you had any major injuries (including concussion, fractures, sprain, strains) since your last physical? 9. Have you had any surgery since your last physical? 10. Have you been hospitalized or had a major illness since your last physical? 11. Has any of your family member recently been diagnosed with any medical problems? 12. FEMALE ONLY - Have you noticed any changes in your menstrual cycle? 13. Do you know of, or do you believe there is any health reason why you should not participate GCU Intercollegiate Athletics at this time? 14. Would you like to be seen by a physician at this time? The undersigned, herewith Understands that having completed this form does not necessarily mean that (s)he is physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify her/him at the time of said examination and certifies that the answers to the questions above are true. STUDENT-ATHLETE SIGNITURE DATE For ATC S Use Only Blood Pressure Height Weight Pulse Visual Acuity(R) (L) STATUS (circle one) CLEARED NOT CLEARED (explain) ATC SIGNITURE DATE

4 Grand Canyon University Athletic Training HEAT ACCLIMATION QUESTIONNAIRE Name Sport Date Please answer all questions at least with yes or no answers. 1. Have you ever had any type of heat related problem (heat exhaustion, stroke, cramps, dizziness, fainting, collapse) before? 2. If you answered yes to the above question, how many times did that particular problem occur, when did it happen, and did you seek treatment? 3. Were you on any form of conditioning program during the summer? If the answer is yes, briefly explain your program. 4. Did you work or work-out in an air-conditioned building during the summer? 5. Are you presently on a diet or a vegetarian? If yes, what kind of diet? Who designed it? 6. How often do you intake fluids during exercise? Do you consume sports drinks during exercise? 7. Have you recently (last 2 weeks) had a cold, problem with vomiting, or diarrhea? If yes, please explain. 8. Are you currently on any medication? If yes, list the name and/or purpose of the medication. NOTICE : If you notice any of the following signs of heat illness, during or after activity, seek attention of athletic trainer immediately: Nausea Fatigue Unsteadiness Weakness Cramping Disturbed vision Decreased sweating Rapid & weak pulse

5 GRAND CANYON UNIVERSITY STUDENT-ATHLETE ACKNOWLEDGMENT AND CONSENT INFORMATION: Acknowledgement of Risk and Consent to Participate: I am aware that the very nature of athletic participation carries with it an inherent risk of injury. I understand that the dangers and risks of participating in athletics, whether in competition or preparing to compete, include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious musculoskeletal injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system, and serious injury or impairment to other aspects of my body and general health and well being. In addition, I am aware that participation in intercollegiate athletics will involve traveling with the team, and that such traveling may expose me to the risks of a motor vehicle accident, as well as other conditions that result from traveling. Having understood the risks of athletic participation and particularly the risk inherent in the sport listed above, I voluntarily assume and accept these risks as they have been explained above. I realize that the coaching staff, athletic trainer, administrators, and other Grand Canyon University personnel will do those things necessary to reduce the risk of injury. However, I realize and accept that these measures will not prevent all athletic injuries to myself or to other student-athletes. I also accept the responsibility in taking personal measures to help prevent injury to myself or other student-athletes by notifying the coaching staff, athletic trainer, administrators or other Grand Canyon University personnel of conditions that I am aware of that may predispose me or other student-athletes to an increased risk of injury resulting from athletic participation. CONSENT TO TREAT AND TRANSPORT: I grant permission to the Director of Health Services, Athletic Trainer or Coaching Staff member from Grand Canyon University to proceed with needed medical and minor surgical treatment, ambulance notification, x-ray and immunization. My signature consents that needed emergency treatment may be given as necessary for the best interest of the student-athlete. In the event that emergency treatment should be necessary, a copy of this permission will be furnished by the physician in charge. CONSENT TO RELEASE OF MEDICAL INFORMATION: As a student-athlete at Grand Canyon University, athletically related injuries may require services of a physician or medical treatment facility. I understand that, as a student-athlete, I am required to carry a primary insurance policy (either institutional student insurance or the student-athlete may be covered under their parent/guardian insurance plan.) All claims will be submitted initially to this plan. The university has insurance coverage for student-athletes as a SECONDARY INSURANCE POLICY FOR ATHLETICALLY RELATED INJURIES ONLY. This means that after the primary plan has considered any claims, the University insurance will take over. For the University to file for benefits under these policies, the student-athlete (or parent/guardian) must provide copies of all bills and primary coverage explanation of benefits (EOB). These copies must be submitted to the University insurance coordinator in a timely manor to prevent delays resulting in late payment of bills. In signing the signature page, I acknowledge my understanding of this policy and grant permission to the Grand Canyon University athletic training staff and/or insurance coordinator to contact my parents/guardians and pertinent medical facilities to gain information regarding insurance and insurance claims information for athletic injury claims at Grand Canyon University.

6 Authorization/Consent for Disclosure of Protected Health Information to the NCAA: My signature on the signature page indicates my consent for Grand Canyon University and its physicians, athletic trainers and health care personnel to disclose my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA) and its employees or agents. I understand that my protected health information will be used only by the NCAA s Injury Surveillance System (ISS) for the purpose of conducting research on injuries resulting from training for or participation in athletics. The ISS is a longitudinal research database that provides the NCAA, NCAA sports rules committees, athletic conferences, researchers and individual schools with summary (aggregate) injury and participation information that does not identify individual athletes or schools. The summary data provide the Association and other groups with an information resource upon which to base health and safety rules and policy and to examine the effectiveness of such efforts. I understand that my injury/illness information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary and that my institution will not condition or withhold any health care treatment or payment, enrollment in a health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation in NCAA athletics. I understand that while HIPAA regulations do not apply to the NCAA s use or disclosure of my injury/illness information, the NCAA is committed to protecting my privacy. I understand that the protected health information will be encoded before being transmitted from my institution to the NCAA and that neither the NCAA nor the ISS will identify me personally in any publication or disclosure of research results. Data will be stored on a secure server at the NCAA national office in Indianapolis, Indiana. This authorization/consent expires 380 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending written notification to the athletics director at my institution. I understand that a revocation takes effect on its request date and does not affect any action taken prior to that date. Acknowledgement of GCU Secondary Insurance Policy: Athletic injuries and their costs are, ultimately, the responsibility of the student athlete, not Grand Canyon University (GCU). The University purchases athletic insurance on the students behalf, and attempts to assist the student with the filing of claims under that policy. However, compliance with the terms and conditions of the policy is also the ultimate responsibility of the student. If the student does not cooperate with the insurance company and follow its rules or if the company determines that the injury or treatment is not covered under the policy and the patient/student does not pay the medical bill by some other means the bills may be sent to a collection agency in the name of the patient: that is, the student athlete. The student s credit rating can be impacted by this non-payment/non-compliance. Athletic insurance is secondary insurance. This means that the insurance company will pay only after you have cooperated in providing information / documentation related to your primary insurance. (For example, the insurance company may require an Explanation of Benefits from the primary carrier.) Student must see a medical professional for an injury no later than 90 days after an initial injury. Issues on such things as obtaining a second opinion, treatment outside the plan, pre-existing conditions, what is or is not an athletic injury, etc. should be directed to the athletic insurance company. GCU personnel cannot answer these questions, but can only assist the student in contacting the carrier for answers. Most important: The issue of an athletic injury is between the student athlete and the insurance company. GCU buys the insurance to supplement the students primary insurance, and helps the student with forms, etc. BUT, GCU personnel are not insurance agents, experts, or parents AND GCU is not responsible for any medical bills incurred by the student athlete. We care about the student and want to help, but the roles must be kept clear. Signature on the signature page indicates that the Student-Athlete (as well as the holder of the primary health insurance policy under which the student-athlete is covered) has read and understands the above information.

7 GCU Intercollegiate Athletics Athletic Training Forms Signature Page In an effort to reduce redundant paperwork in your student-athlete file in the athletic training room, this document has been created to allow for you to indicate your acknowledgement, consent and acceptance of the policies and/or procedures in the GCU Student-Athlete Acknowledgement and Consent Information pages. Acknowledgement of Risk and Consent to Participate: I have read the statement and understand that participating in athletics has inherent risks of possible bodily damage or injury as explained. I voluntarily assume and accept the risk of participating in intercollegiate athletic activities at Grand Canyon University CONSENT TO TREAT AND TRANSPORT: I have read the statement and consent that needed emergency treatment may be given as deemed necessary by authorized personnel. CONSENT TO RELEASE OF MEDICAL INFORMATION: I have read the statement and acknowledge my understanding of this policy and grant permission to the Grand Canyon University athletic training staff and/or insurance coordinator to contact my parents/guardians and pertinent medical facilities to gain information regarding insurance and insurance claims information for athletic injury claims at Grand Canyon University. Authorization/Consent for Disclosure of Protected Health Information to the NCAA: I have read the statement and consent for Grand Canyon University and its physicians, athletic trainers and health care personnel to disclose my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA) and its employees or agents. Acknowledgement of GCU Secondary Insurance Policy: I (as well as the holder of the primary health insurance policy under which the student-athlete is covered) have read the statement and understand the stated information regarding GCU s Secondary Athletic Related Insurance coverage. Student Name: Sport: Signature: Date Signed: If Student Athlete is a Minor (not yet 18 years of age) Parent/Legal Guardian must also sign below Parent: Date Signed: