SMSU Athletic Training and Sports Medicine

Transcription

1 - This document contains important information as well as the forms which need to be completed prior to participating in intercollegiate athletics at Southwest Minnesota State University. This information covers the protocols of the Athletic Training and Sports Medicine Team and contact information. The completed forms are necessary to provide appropriate medical care to our student athletes and maintain our compliance with the NCAA. SMSU Athletic Training and Sports Medicine

2 Dear Parent/Student-Athlete: On behalf of the Southwest Minnesota State Sports Medicine Staff we would like to welcome you to SMSU Athletics. We would like to take this opportunity to introduce ourselves and to share some important information with you regarding our Sports Medicine policies and procedures Our Sports Medicine Staff consists of two team physicians, three full time Certified Athletic Trainers and four graduate assistant Certified Athletic Trainers. Our information is included later in this packet. It is our goal to provide our student athletes with the best possible medical care. The following pages contain information about what to expect during your time with SMSU Athletics. SMSU ATHLETICS DOES NOT PROVIDE ANY PRIMARY OR SECONDARY ATHLETIC INSURANCE COVERAGE. ALL STUDENT-ATHLETES ARE REQUIRED TO HAVE PERSONAL INSURANCE, EITHER THEIR OWN OR THROUGH THEIR PARENTS/GUARDIANS. This insurance MUST cover the student athlete for treatment in Marshall, Minnesota and must cover a minimum of $90,000 per injury in coverage. If, in the best judgment of the sports medicine staff, it becomes necessary to seek medical attention for an injury incurred by the student-athlete, we will assume that you have made arrangements for this possibility. It is impossible for our staff to know the details of each student s primary policy. Please familiarize yourself with the rules/requirements of the primary insurance policy under which you are covered. It is advisable to let your insurance company know that a dependent is travelling away from home for educational reasons so that you are aware of what will be required in the event a claim must be filed. Should a student athlete incur a medical expense, the student s personal insurance will be billed by the service provider. If there is an outstanding balance after the primary insurance processes the claim, the student athlete and/or parents will be responsible for the remaining balance. In the event of an injury which requires off-campus care, athletes will be referred to team physicians provided by Affiliated Community Medical Center and Orthopedic Institute. Our SMSU Sports Medicine staff will facilitate this referral. All sports medicine decisions are unique and determined by a variety of factors: type and severity of injury, insurance coverage, time of day, and schedule of the athlete. We typically utilize the SMSU Student Health service for illnesses, ACMC clinic and Urgent Care for non-emergent injuries and illnesses, Orthopedic Institute for free orthopedic consultations (weekly) and Avera Hospital for emergent or after-hours needs. If an athlete and/or parents wish to use a different physician or to have a second opinion, that is encouraged. However, please keep in mind that if there are any conflicts, the final authority for determining any student-athlete s return to play will be SMSU team physicians. Please return the following forms, to SMSU Athletic Training, no later than July 1, 2015 (sooner if possible) ALL forms (located on pages 18-28) must be completed and on file in the athletic training room before any student athlete is eligible for participation in any intercollegiate activity. Health History Form Physical Exam Form (must be completed between 5/1/2015 and 8/1/2015) Emergency Contact Information/Medical Consent and Procedures Agreement Athlete Insurance Information Insurance Agreement/Statement of Informed Risks Authorization/Consent Form for Disclosure of Protected Health Information. (Need only be completed once unless rescinded in writing). Sickle Cell Trait Information and Waiver (Need only be completed once. Waiver is unnecessary if documentation/results are provided of sickle cell trait test) Sickle Cell Trait Positive Notification Form (completed only by athletes who carry the sickle cell trait) NCAA Banned Substances Medical Exceptions Notification Form Concussion Disclosure Form MAIL/FAX/ ALL FORMS TO YOUR HEAD COACH ATTN: (insert coach name) OR Laura Crowell, MS, ATC Southwest Minnesota State University Head Certified Athletic Trainer 1501 State Street 1501 State Street Marshall, MN Marshall, MN FAX

3 SMSU SPORTS MEDICINE TEAM Team Physician Dr. Jill Vroman ACMC Marshall Family Medicine Team Physician Orthopedics Dr. Evan Hermanson Orthopedic Institute 810 East 23rd St. P.O. Box 5116 Sioux Falls, SD Head Athletic Trainer Laura Crowell, MS, ATR SMSU Office: Fax: Assistant Athletic Trainer Jodi Fuerstenberg, ATR SMSU Office: Fax: Assistant Athletic Trainer Patty Myrvik, MS, ATR SMSU Office: Fax: Graduate Assistant Athletic Trainer TBD SMSU Office: Fax: Graduate Assistant Athletic Trainer TBD SMSU Office: Fax: Graduate Assistant Athletic Trainer TBD SMSU Office: Fax: Graduate Assistant Athletic Trainer TBD SMSU Office: Fax:

4 IMPORTANT INSURANCE INFORMATION 1. SMSU Athletics does NOT provide any primary or secondary athletic insurance coverage. 2. SMSU requires student-athletes to carry primary insurance coverage that will cover the deductible on the NCAA Catastrophic Insurance Policy which is currently $90,000/injury. 3. It is the responsibility of the student athlete/parent to determine that they carry appropriate insurance coverage. Students should be aware of the following issues regarding appropriate coverage: a. The Affordable Care Act requires everyone to have health insurance or be subject to penalties. There are several options available to students, including coverage under a parent's policy until age 26 or by purchasing coverage through the Minnesota Health Insurance Exchange (MNsure). Students may enroll or seek additional information at MNsure.org. Students from states other than Minnesota should explore options within their state of permanent residence. If you need further assistance with insurance purchase, please see the information below. b. MNSCU international student health care policy does not meet the requirements for intercollegiate athletes. Even with the purchase of the sports rider, this policy has a limited benefit amount which is far less than the required $90, Students who are enrolled in a managed care health plan MUST be aware of the limitations of their primary policy. Most of the athletic health care that we provide and assist with is non-emergent care. It is helpful if a student is able to make the local clinic his/her primary care clinic. If the student is out-of-network, he or she will be required to follow the policies of the primary insurance. What do I do if my insurance does not meet the criteria required by the university? With the implementation of the Affordable Care Act, hopefully you obtained insurance prior to the deadline. If not, you may still have some options and are free to pursue any option available to you. SMSU has worked with a local insurance company to assist students with the purchase of a primary insurance policy. The available options are often dependent on individual circumstances. The following individual is available to assist with this process: Benjamin Wiener (507) It may be possible for the student athlete to utilize his/her financial aid to assist in the cost of the insurance. Unless a student is already taking the maximum loan amount, the student may be eligible to increase their student loan amounts. Please contact the SMSU financial aid office to see if this is possible for your specific situation. Price Estimates for these plans are listed below, but are subject to change: o o PreferredOne Copay Plans (nonsmoker) o $1000 deductible = $156/month o $2000 deductible = $146/month o $3500 deductible = $132/month o $4400 deductible = $126/month o $6350 deductible = $110/month PreferredOne Deductible Plans (nonsmoker) o $750 deductible = $172/month o $2000 deductible = $148/month o $3500 deductible = $126/month o $5700 deductible = $100/month o $6300 deductible = $94/month

5 MEDICAL COVERAGE OF PRACTICES/GAMES Student/Parent Fact Sheet Every attempt is made to have a Certified Athletic Trainer present or accessible at practices and games. The detailed coverage protocol is available and on file in the Head Athletic Trainers office. INJURY PROCEDURE What to expect if an injury occurs: Emergent Situations (life threatening/catastrophic): A member of the athletic training staff will evaluate injured athletes and determine severity. Emergent situations will be handled per the Emergency Action Plan (EAP) for each sport and venue. Appropriate emergency first aid will be administered in addition to efficient transportation and referral to appropriate medical personnel Parents will be contacted utilizing the information on the Emergency Contact Information Form A written record of the injury will be on file with the SMSU Sports Medicine Team. Non-emergent situations (dislocations, fractures, sprains, strains etc.): In most cases parents will NOT be contacted in the event of a non-emergent injury. The student athlete will be advised to communicate the injury status with parents. If a parent has questions or concerns they are encouraged to discuss this with the student athlete prior to calling the athletic trainer. The ATC will choose the appropriate course of action by interpreting the signs and symptoms of the illness/injury. The ATC will obtain a medical history from the individual to determine the pathology and extent of the injury/illness The ATC will inspect, palpate, and perform special tests to the injured area using bilateral comparison to determine the extent of the injury/illness SMSU Athletic training staff will administer appropriate first aid and when necessary make referrals to appropriate medical personnel (every attempt will be made to comply with the dictates of the student insurance and wishes) PLEASE NOTE: Students over the age of 18 will be making decisions; it is advised that the family discuss options prior to the occurrence of an injury. The ATC will administer follow-up care with the use of modalities such as cold, heat, sound, electricity, exercise and mechanical devices (crutches, walking boots, etc.) for treatment and rehabilitation of athletic injuries to athletes. An individualized treatment plan will be developed for the injured athlete based on the following athletic training responsibilities: o The ATC will evaluate and re-evaluate the injury/illness to determine the appropriate rehabilitation programs o The ATC will make every attempt to restore normal function utilizing appropriate therapeutic exercises and modalities o The ATC will assess functional status in order to ensure a safe return to activity Referrals to Physicians: When necessary, injured or ill athletes will be referred into the care of a physician based on the following criteria: Emergencies will be handled via the emergency care plan as detailed above. Non-emergency orthopedic injuries will be referred to Dr. Jill Vroman or Dr. Evan Hermanson when appropriate, based on availability of the physician. Non-emergency orthopedic injuries, which must be handled immediately (fractures, dislocations etc.), will be referred to Dr. Jill Vroman. If during ACMC Urgent Care hours, the referral will be to the on-call Urgent Care Physician. If the injury occurs after hours (including urgent care hours), the athlete will be referred to the emergency room at Avera Marshall Regional Medical Center.

6 Illnesses will be referred first to the Southwest State University Health Center. If the Health Center is closed, athletes may be referred to Dr. Jill Vroman or the urgent care physician at Affiliated Community Medical Center. When appropriate, all referrals will be made with consideration given to the athlete s medical insurance requirements. Communication: Parents are notified by Sports Medicine Staff in the event of life threatening or catastrophic injuries In general, parents are NOT notified by SMSU Sports Medicine Staff in the event of non-emergent injuries (dislocations, sprains, strains, fractures etc.). However, communication can be initiated by the parent with the approval of the student-athlete. We strive to provide excellent health care to our student-athletes. Critical to this objective is the need to keep open lines of communication between several parties (coaches, professors, administrators, and other health care providers) for this reason, athletes should not report to the Health Center or ACMC without first consulting the athletic training staff. In the event of an emergency, the athlete should seek medical assistance; however, the athletic training staff must be notified as soon as possible. This insures that records are accurate, follow-up care is appropriate, and everyone is on the same page. Who decides? In most situations, the attending physician and/or the athletic training staff shall be the judge as to when an ill or injured athlete is able to return to practice for general conditioning and also when he/she is available for full participation. In the event of a conflict between attending physician and team physician, the team physician has the final authority over return-to-play decisions. We discourage any attempt to speed up our return-to-play protocols in the event of concussion injuries. In the event of surgery, the attending surgeon will be the sole judge as to when the athlete will be released. A written release for the athlete must be on file before returning to activity. Miscellaneous: Athletes with minor injuries: cuts, scratches, abrasions, bruises, blisters, etc. should report to the training room after showering. No athlete will be excused from attending practices because of colds, upset stomach, diarrhea, minor injuries, etc. without the athletic training staff, or physician s consent, these decisions will be made in tandem with the coaching staff. Athletes should report illnesses or injuries to the athletic training staff prior to 11am. This ensures that there is ample time to make appropriate referral decisions, and this allows the coaching staff time to alter practice plans. We encourage responsible timely communication and we do not force anyone to practice when they are ill or injured. If it is not important enough to report in the morning, it is not important enough to limit practice. Coaches will be kept informed of the injured/ill athlete s health status by the athletic trainer. Information concerning the athlete s medical condition is confidential. The athletic training staff will not release medical information to anyone outside of the athletic department, without a written consent form on file.

7 SMSU Athletic Training Room Policies and Procedures LOCATION BA 130B TRAINING ROOM TARGET CLIENTS A. The Southwest Minnesota State University Athletic Training facility is designed to deliver traditional athletic training and sports medicine services to student-athletes who compete in intercollegiate sports at Southwest Minnesota State University. Every courtesy will be extended to student-athletes who visit SMSU for the purpose of intercollegiate competition. B. In the event of an emergency, SMSU athletic training staff will render emergency first aid to others on the SMSU campus. TRAINING ROOM SCHEDULE (August 1- May 10 th ) (any changes will be posted) Monday Friday: 9:00-12:00 Treatment and Rehabilitation 1:30-3:30 Pre Practice Preparations 3:30-5:30 Practice Coverage Post-Practice Training room will close 30 minutes post practice (Depending on number of injuries) Saturday/Sunday Summer Hours: EVENT COVERAGE ONLY By appointment only Appointments can be scheduled on-line by following this link: Fall camp and winter break schedules will be determined by practice times. In general the athletic training room will be open one hour prior to practice. The athletic training room will close shortly after the last practice concludes. During fall camp and winter break, if there are large gaps in the time between practice sessions, the athletic training room may not be open. During the time periods that the training room is closed, a large cooler of ice and bags will be available outside the athletic training room door. ATHLETIC TRAINING ROOM OPERATING POLICIES Athletes experiencing a new injury are welcome to walk-in. Follow up treatments and rehabs are scheduled by appointment due to limited space. In the event of a scheduling conflict, priority will be given to the in-season athlete. Orthopedic clinic is currently scheduled for Mondays, some flexibility in scheduling is required on this day. Post-practice treatments are for new injuries only. All other treatments/rehabs are to be done during regular treatment hours. Special treatment hours may be arranged at the discretion of the athletic training staff If we instruct you to come in for treatment/rehab we expect you to show up. If you do not provide reasonable notice, your coach will be informed and we will assume you are able to participate fully in practice. A certified athletic trainer must directly supervise all full-service athletic training facilities during the declared hours of service. If a Certified Athletic Trainer is not in the athletic training room, there will be no treatments allowed (except ice will be available). The training room will remain locked at all times when an ATC is not physically present. SMSU security has been directed that the door is not to be opened for anyone. The athletic training room staff reserves the right to close the TR earlier than 6:00 PM on days that have no scheduled practices at that hour and no scheduled treatments.

8 ATHLETIC TRAINING ROOM RULES OF CONDUCT No profanity No theft No horseplay No tobacco in any form No harassment Taking photographs with mobile devices in the training room is prohibited. When possible, athletes should shower before receiving treatment Clean up after yourself (empty ice bags, put dirty towels in the hamper, throw away used ice cups, etc.) Athletes who have scheduled a treatment/rehab have priority over those who have not signed up. The athlete who is late for his/her appointment will have his/her treatment time adjusted accordingly if there is an appointment waiting. Athletes must report to the athletic training room by 11:00 if they feel that the injury or illness will warrant a change in practice status. Injury reports will be made available to coaches at noon. Athletes are encouraged to phone if they will be unable to report. Last minute complaints are strongly discouraged. All athletic training room equipment remains in the athletic training room unless checked out to you by a staff member. Unreturned or damaged items will be charged to your (student) fee statement. You must check in any returned items with a staff member We will not provide OTC medications (Advil, Aleve, Allergy, etc.) on a daily/routine basis. Wrestling Only: Herpes Simplex medication: we choose to prophylactically medicate for the herpes simplex virus. Those individuals that have followed this course of treatment have remained herpes free. It is not required, but is highly recommended.

9 Health Care Options for SMSU Student-Athletes SMSU Sports Medicine Options General Medical Care SMSU Health Center Bellows Hall Affiliated Community Medical Center Team Physician Dr. Jill Vroman Clinic and Urgent Care 1521 Carlson Street, Marshall MN Emergency Medical Care Avera Regional Medical Center 300 S Bruce St, Marshall MN Orthopedics Orthopedic Institute Outreach Team Physician Dr. Evan Hermanson 810 East 23rd St, Sioux Falls SD Other Health Care Options in Marshall General Medical Care Avera Regional Medical Center (Family Practice and Curaquick Clinic) 300 S Bruce St, Marshall MN Orthopedics Avera Regional Medical Center Dr. Vikram Chatrath 300 S Bruce St, Marshall MN Orthopedic Institute Outreach Dr. Eric S Watson 810 East 23rd St, Sioux Falls SD Southwest Minnesota Orthopedic & Sports Medicine, Inc. Dr. Anthony Nwakama 1401 Nwakama St, Marshall, MN

10 Dental Anthony Parisek Dental Health Center Marshall Dental Excellence Johnson Family Dentistry Oral-Facial Surgery Smile Designers Lecy Orthodontics Eye Care Midwest Vision Center Walmart Eye Care Shopko Eye Care Heartland Eye Care Taft Optical Avera Eye Care Pharmacy Hy-Vee Hy-Vee Clinic Walmart Shopko Thrifty Drug Chiropractic Bruns Chiropractic Complete Chiropractic Fixen Chiropractic Hoganson Chiropractic Lastine Chiropractic Preferred Health Chiropractic Sherman Chiropractic & Rehabilitation

11 INFORMATION SHEET FOR NCAA BANNED SUBSTANCES NCAA BANNED DRUG LIST The NCAA bans the following classes of drugs: a. Stimulants b. Anabolic Agents c. Alcohol and Beta Blockers (banned for rifle only) d. Diuretics and Other Masking Agents e. Street Drugs f. Peptide Hormones and Analogues g. Anti-estrogens h. Beta-2 Agonists Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned drug class regardless of whether they have been specifically identified. Drugs and Procedures Subject to Restrictions: a. Blood Doping. b. Local Anesthetics (under some conditions). c. Manipulation of Urine Samples. d. Beta-2 Agonists permitted only by prescription and inhalation. e. Caffeine if concentrations in urine exceed 15 micrograms/ml. NCAA Nutritional/Dietary Supplements Warning: Before consuming any nutritional/dietary supplement product, review the product with the appropriate or designated athletics department staff! Dietary supplements are not well regulated and may cause a positive drug test result. Student-athletes have tested positive and lost their eligibility using dietary supplements. Many dietary supplements are contaminated with banned drugs not listed on the label. Any product containing a dietary supplement ingredient is taken at your own risk. Note to Student-Athletes: There is no complete list of banned substances. Do not rely on this list to rule out any supplement ingredient. Check with your athletics department staff prior to using a supplement. Some Examples of NCAA Banned Substances in Each Drug Class Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen); methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange); methylhexaneamine, bath salts (mephedrone) etc. Exceptions: phenylephrine and pseudoephedrine are not banned. Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione): boldenone; clenbuterol; DHEA (7-Keto); nandrolone; stanozolol; testosterone; methasterone; androstenedione; norandrostenedione; methandienone; etiocholanolone; trenbolone; etc. Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc. Diuretics (water pills) and Other Masking Agents: bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. Street Drugs: heroin; marijuana; tetrahydrocannabinol (THC); synthetic cannabinoids (eg. spice, K2, JWH-018, JWH-073) Peptide Hormones and Analogues: growth hormone (hgh); human chorionic gonadotropin (hcg); erythropoietin (EPO); etc. Anti-Estrogens: anastrozole; tamoxifen; formestane; 3,17-dioxo-etiochol-1,4,6-triene(ATD), etc. Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; etc. Any substance that is chemically related to the class, even if it is not listed as an example, is also banned!

12 The most Frequently Asked Question with regard to NCAA banned substances is how to prepare for the athlete who is currently being treated for Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder with a prescribed medication that is on the NCAA Banned Substance list? The NCAA recognizes that some banned substances are used for legitimate medical purposes. Accordingly, the NCAA allows exceptions to be made for those student-athletes with a documented medical history demonstrating the need for regular use of such a drug. Exceptions may be granted for substances included in the following classes of banned drugs: stimulants (including those used to treat ADHD), beta blockers, beta-2 agonists, diuretics, peptide hormones, anabolic agents and anti-estrogens. Pre-approval is required for the use of peptide hormones or anabolic agents. The institution must submit required documents prior to the student-athlete competing while using medications containing these substances. For all other drug classes, the institution should maintain documents from the prescribing physician in the studentathlete s medical record on campus that includes the diagnosis, course of treatment and current prescription. In the event that a student-athlete tests positive by the NCAA, the institution will be notified of the positive drug test, and at that time the director of athletics may request an exception by submitting required documents. Requests for exceptions will be reviewed by the chair of the drug-testing and drug-education subcommittee of the CSMAS and reported back to the institution. The NCAA published guideline information for the criteria necessary to receive an exception. The criteria for a letter from the prescribing Physician to provide documentation to the Athletics Department/Sports Medicine Staff regarding assessment of student-athletes taking prescribed stimulants for ADHD, ADD, in support of an NCAA Exception request for the use of a banned substance. The following must be included in supporting documentation: Student-athlete name. Student-athlete date of birth. Date of clinical evaluation. Clinical evaluation components including: Summary of comprehensive clinical evaluation (referencing DSM-IV criteria) -- attach Supporting documentation. ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores and report summary -- attach Supporting documentation. Blood pressure and pulse readings and comments. Note that alternative non-banned medications have been considered, and comments. Diagnosis. Medication(s) and dosage. Follow-up orders. Additional ADHD evaluation components if available: Report ADHD symptoms by other significant individual(s). Psychological testing results. Physical exam date and results. Laboratory/testing results. Summary of previous ADHD diagnosis. Other comments. Documentation from prescribing physician must also include the following: Physician name (Printed) Offices address and contact information. Specialty. Physician signature and date.

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15 SMSU Concussion Management Plan Information Sheet This is the process followed in the event of a concussion (mild traumatic brain injury) while participating in intercollegiate sports at SMSU. PRIOR TO INJURY: Obtain Baseline Testing: Our testing tools include the SCAT 3, ImPACT, Sway, and King Devick. Baselines are obtained for all student- athletes. POST INJURY: Concussion Identified and Assessed: Physical examination and assessment of concussion symptoms by sports medicine staff (athletic trainer, physician assistant and/or physician). If physician not immediately available and the situation is emergent, athlete should be transported to closest emergency department. If the situation is not emergent, athlete will be referred to physician for evaluation prior to a return to play decision. SMSU sports medicine staff will be in regular communication with team physician regarding athlete care. Athlete will be held from all physical activity; given concussion information home instruction sheet; athlete will repeat testing within 24 hours of injury or as soon as physically possible. Concussion Management: Athlete held from all physical activity; advise athletes on voluntary implementation of DHA Omega-3 supplementation (3 grams daily for 30 days or until asymptomatic if longer); re-assess athlete daily by medical staff; administer symptom checklist daily until completely asymptomatic; provide documentation of injury to athletes for professors ( for purpose of consideration of academic modifications/restrictions) Athlete Asymptomatic: Athlete repeats baseline testing (unless directed otherwise by physician) Test Results Return to Baseline: Perform exertional testing (see side 2); re-evaluation by physician for return-to-play decision Test Results NOT Returned to Baseline: Repeat test battery at physician s discretion; consider neuropsychology consult with more detailed test battery. When medically cleared by physician, perform exertional testing; re-evaluation by physician for return-to-play decision

16 Exertional Testing Protocol Following Concussion Symptom checklist and specific testing are all WNL Exertional Testing Protocol Step 1 10 min on stationary bike; exercise intensity <70% maximum predicted heart rate Step 2 10 min continuous jogging on treadmill; exercise intensity <70% maximum predicted heart rate Step 3 Strength training: (i.e. push-ups, sit-ups, squats thrusts) Step 4 Advanced cardiovascular training: sprint activities Step 5 Advanced strength training: weight lifting exercises Step 6 Sport specific agility drills (no risk of contact) If no change or increase in symptoms, move to next step. Non-contact practice following completion of exertional testing protocol If no change or increase in symptoms, move to next step. Limited to full contact practice If no change or increase in symptoms, final return-to-play decision made by medical staff. ROLE DELINEATION of Concussion Management Program: Physician: Final authority in return to play decisions; interpreter of ImPACT results; prescriber of medication; referral source if required to neurology or neuropsychology specialist; oversight of concussion management plan. Certified Athletic Trainer: Authority for baseline testing, referral to team physician or on-call physician, daily monitoring and care; post-testing, athlete advocate; oversight of exertional testing, liaison with parents and coaches.

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18 HEALTH HISTORY FORM Completed form should be reviewed with physician at PPE and also turned into the SMSU Athletic Training Staff Name Sex Age Date of birth Eligibility Status: Fr So Jr Sr 5th Sport(s) Personal physician Physician Address Physician Phone Please answer all questions and explain yes answers in the space provided. YES NO 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have an ongoing medical condition (like diabetes or asthma)? 3. Have you ever spent the night in a hospital? 4. Have you ever had surgery? Explain Date/s 5. Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills? Current Medications/Supplements (list all): (Medications for ADD/ADHD require additional documentation for the NCAA; please review enclosed information) 6. Do you cough, wheeze, or have difficulty breathing during or after exercise? 7. Is there anyone in your family who has asthma? 8. Has a doctor ever told you that you have asthma or allergies? Drugs Foods Inhalants Do you carry an Epi-pen for your allergy? Pollens Contacts Insects 9. Have you ever used an inhaler or taken asthma medicine? 10. Have you ever passed out or nearly passed out DURING exercise? 11. Have you ever passed out or nearly passed out AFTER exercise? 12. Have you ever had discomfort, pain, or pressure in your chest during exercise? 13.Does your heart race or skip beats during exercise? 14 Has a doctor ever told you that you have (check all that apply): High blood pressure Bleeding/clotting disorder A heart murmur High cholesterol A heart infection 15. Has a doctor ever ordered a test for your heart? (For example, ECG, echocardiogram) 16. Has anyone in your family died before the age of 35? Who/Why? 17. Has anyone in your family died before the age of 50? Who/Why? 18. Does anyone in your family have a heart problem? Who/What? 19. Does anyone in your family have Marfan syndrome? Who? 20. Have you ever had a head injury or concussion? If yes, how many concussions have you experienced? If yes, what was the date of the last concussion? Did you lose consciousness as a result of a concussion? 21. Have you been hit in the head and been confused or lost your memory? 22. Do you have headaches with exercise? 23. Do you suffer from migraine headaches? 24. Have you ever had a seizure? 25. Have you had numbness, tingling (exclude stingers), or weakness in your arms/legs after being hit or falling? 26. Have you ever been unable to move your arms or legs after being hit or falling? 27. Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?

19 28. Were you born without or are you missing a kidney, an eye, or any other organ? 29. Have you had infectious mononucleosis (mono) within the past two months? 30. Do you have any rashes, pressure sores, or other skin problems? 31. Have you had a herpes skin infection? 32. When exercising in the heat, do you have severe muscle cramps or become ill? 33. Have you had any heat related illness (heat cramps, heat exhaustion, heat stroke)? 33. Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell anemia? 34. Have you had any problems with your eyes or vision? 35. Do you wear glasses or contact lenses? 36. Do you wear protective eyewear, such as goggles or a face shield? 37. Do you have hearing problems? 38. Do you wear any dental appliance? List 39. In the last year, what was your : Lowest weight Highest weight 40. Are you happy with your weight? 41. Has anyone recommended you change your weight or eating habits? 42. Do you currently have any injuries? What/when? 43. Have you ever had an injury which caused you to miss a practice or game? 44. Have you ever fractured a bone? Which bone(s)? Date 45. Have you ever injured your shoulder? Left Right Explain Date 46. Have you experienced a stinger/burner? How many? Date 47. Have you ever injured your hands/wrists? Left Right Explain Date 48. Have you ever injured your back? Explain Date 49. Have you ever injured your knee? Left Right Explain Date 50. Have you ever injured your lower leg? Left Right Explain Date 51. Have you ever injured your ankle? Left Right Explain Date 52. Have you ever had an injury, like a sprain, muscle or ligament tear or tendinitis? 53. Have you ever dislocated a joint? Explain Date 54. Have you ever had a stress fracture? Explain Date 55. Have you had a bone or joint injury that required: x-rays MRI CT Surgery injections, rehabilitation physical therapy brace cast crutches Explain Females Only 56. Do you have a menstrual cycle? Age of onset? 57. Do you have any menstrual problems? Males Only 58. Do you have or have you had a hernia? 59. Do you have loss of function or absence of testicle or any related problem? I have answered all the above questions truthfully and understand that withholding any history or prior illness may release Southwest Minnesota State University from any financial responsibility or legal liability for a preexisting problem. Athletes Printed Full Name Date Athlete s Signature Parent/Guardian s Signature Date (if athlete is under 18 years of age)

20 PHYSICAL EXAMINATION FORM Exams must be performed by MD, DO, CPA, or CNP NAME Date of birth Height BP / ( /, / ) Weight Vision R 20/ L 20/ Corrected: Y N % Body fat (optional) Pupils: Equal Unequal Pulse MEDICAL Normal Abnormal Findings Appearance Eyes/Ears/Nose/Throat Hearing Lymph nodes Heart Murmurs Pulses Lungs Abdomen Genitourinary Skin MUSCULOSKELETAL Normal Abnormal Findings Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Sickle Cell Trait Testing: The NCAA mandates that medical examinations for athletic participation include sickle cell trait testing to ensure that all NCAA student-athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. Sickle cell trait testing is not required by NCAA when a student-athlete provides documented prior results to the institution OR knowingly and voluntarily declines testing. In order to decline, the athlete must participate in the SMSU Sickle Cell Trait educational program and sign the Sickle Cell Trait Testing and Waiver Form Tested for sickle cell trait on (date). Positive Test Negative Test Declined sickle cell trait test (must complete Sickle Cell Trait Testing and Waiver Form). Abstains from reporting at this time (documentation is already on file or will be provided separately to SMSU AT staff). Cleared without restriction Cleared, with recommendations for further evaluation or treatment for: Not cleared for certain sports: Not cleared for all sports. Recommendations: Physicians Certification: I certify that I have examined this student. On the basis of this examination and the medical information as presented to me, I have found no reason which would make it medically inadvisable for this student to participate and compete in intercollegiate athletics. Any exceptions are listed above. Print Physicians Name: Physicians Address: Phone: Physician s Signature: Date:

21 EMERGENCY CONTACT INFORMATION Name SMSU ID number Student s Cell Phone: Student s Marshall Address (dormitory or apartment) Father/Guardian Primary Emergency Contact Secondary Emergency Contact Name: City: Home Phone Cell Phone: Mother/Guardian Home Address: State: Zip: Work Phone: Primary Emergency Contact Secondary Emergency Contact Name: City: Home Phone Cell Phone: Third Emergency Contact (Required) Name: Home Phone: Address: Home Address: State: Zip: Work Phone: Relationship Work/Cell Phone: City: State: Zip: MEDICAL CONSENT AND PROCEDURES AGREEMENT In consideration for being allowed to participate in Southwest Minnesota State University s Intercollegiate Athletic Program, I/we hereby grant permission to Southwest Minnesota State University, its physicians, and/or certified athletic trainer(s) to render and/or authorize preventative care, first aid, treatment, rehabilitation, and/or emergency treatment deemed reasonably necessary to protect my health and well-being. Emergency care may include hospitalization, treatment, or surgery at a competent and/or accredited facility when necessary for the protection of the athlete s health and well-being. I release and agree to indemnify and hold harmless Southwest Minnesota State University, its Board, President, officers, employees and team physicians against and from any and all claims, damages and expenses arising out of or resulting from such injuries, losses and medical treatment or care. As a student-athlete at Southwest Minnesota State University I understand that: 1. I agree to use all safety equipment that is issued to me by my coach, equipment manager, or certified athletic trainer. I further agree not to alter or change my protective equipment without obtaining permission from my athletic trainer. This includes all braces, protective gear, mouth pieces, and uniforms 2. If suffering from an illness or injury, I will notify the sports medicine staff as soon as possible. 3. If suffering from an illness or injury, I will follow the directions of the designated health care personnel. 4. If the services of a physician are required, except in cases of emergency, I should first consult with a member of the university s sports medicine staff. 5. I am required to report to all scheduled appointments in the Sports Medicine Facility when I am receiving care for an injury. If I cannot attend, I will call and notify the proper sports medicine personnel. 6. After suffering from an injury or illness, proper medical clearance in writing from the attending medical personnel, must be obtained in order to return to activity. 7. The Southwest Minnesota State University Department of Athletics is NOT responsible for illness or injury related to intercollegiate athletics participation. Athlete Parent/Guardian (Must be signed if athlete is under 18 years old) Spouse (Must be signed if athlete is married) Date Date Date

22 ATHLETE INSURANCE INFORMATION 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 in the file! Athlete s Full Name Sport Athlete s Permanent (Billing) Address Primary Insurance: Name of Insurance Company ID Number Mailing Address for Claims Insurance Company Telephone Number Policy Holder Name Date of Birth Home Address Home Telephone Employer Name Employer Telephone Secondary Insurance: Employer s Address Is the athlete covered under the above policy? Yes No Is this policy an HMO PPO Other Does your insurance require preauthorization for service? Yes No Authorization Phone Number Does this policy cover athletic injuries? Yes No Is this policy claims eligible in Minnesota Yes No Does this policy cover the student for injury or illness at ACMC- Marshall Yes No ; as Avera-Marshall Yes No Name of Insurance Company ID Number Mailing Address for Claims Insurance Company Telephone Number Policy Holder Name Date of Birth Home Address Home Telephone Employer Name Employer Telephone Employer s Address Is the athlete covered under the above policy? Yes No Is this policy an HMO PPO Other Does your insurance require preauthorization for service? Yes No Authorization Phone Number Does this policy cover athletic injuries? Yes No Is this policy claims eligible in Minnesota Yes No Does this policy cover the student for injury or illness at ACMC- Marshall Yes No; at Avera-Marshall Yes No SMSU Team Physicians Dr. Jill Vroman: Affiliated Community Medical Center (ACMC) Specialty: Family Practice Dr. Evan Hermanson: Orthopedic Institute, 810 East 23rd Street Sioux Falls, SD Specialty: Orthopedics SMSU Student Athletes have the following health care options: SMSU Health Center, BA 158 Nurse hours: M-F; 9-4:00 PA/CNP hours: M, T, TH; 1-4 pm SMSU Free Orthopedic/Sports Clinic: Mondays at ACMC Bruce Street Location with Dr. Evan Hermanson ACMC 1521 Carlson Street; M-F 8am-5pm (our physician of choice is Dr. Jill Vroman) ACMC Urgent Care 1521 Carlson Street; M-F 8am-8pm, Sat & Sun 9:00am-4:00pm Avera Marshall Regional Medical Center Emergency Room 300 S. Bruce Street Avera Curaquick Clinic (located in Hy-Vee) 900 E Main Street; M-F 9:00am-7:00pm, Sat 9am-1pm, Sun 12-4pm PLEASE NOTE: You may want to consider transferring your medical insurance coverage to the Marshall area while you are participating in intercollegiate athletics. If you are covered by an HMO or PPO, your medical expenses may not be covered in this area. It becomes very inconvenient for athletes who are required to travel great distances to receive in-network medical care. The student-athlete needs to be responsible for and aware of what health care options he/she can pursue locally. SMSU is not responsible for out-of-network charges.

23 INSURANCE AGREEMENT Athlete Name Sport SMSU DOES NOT PROVIDE ANY PRIMARY OR SECONDARY ATHLETIC INSURANCE I certify that I am adequately covered by an insurance policy which will provide coverage to a minimum of $90,000, in Marshall, Minnesota. I understand and agree that SMSU will assume no responsibility whatsoever for the payment of, or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at SMSU. I understand that it is my responsibility to familiarize myself with all the requirements of my primary insurance policy and to make decisions accordingly. I understand that if my insurance information changes it is my responsibility to provide the new information to Southwest Minnesota State University. I understand that if at any time I become uninsured, I become solely responsible for all medical costs incurred as a result of injury while at Southwest Minnesota State University. I hereby state that I am the policyholder and/or policy beneficiary and I am authorized to make these decisions. The signatures also authorize Southwest Minnesota State University and their insurance agency to inspect or secure copies of case history reports, laboratory reports, diagnoses, X-rays and other data. A photo static copy of this authorization will be deemed as effective and valid as the original. I certify that the information provided to Southwest Minnesota State University is true and accurate. Date Athlete Signature Date Policy Holder Signature STATEMENT OF INFORMED RISKS Date Student Athlete I wish to participate in Southwest Minnesota State University intercollegiate athletics being engaged in the intercollegiate sport(s) of I hereby acknowledge that I am participating in these activities with the full realization that they may involve a significant risk of bodily injury. I understand that the injury may range in severity from minor to long term catastrophic up to and including death, or damage to property of me and others. I am aware that it is not possible to delineate specifically each and every individual injury risk. However, knowing the material risk and appreciating and reasonably anticipating that injuries and even death are a possibility, I hereby expressly assume all of the risks which could occur as a result of my participation. I agree that in exchange for and in consideration of Southwest Minnesota State University permitting me to participate in this sport and all activities related to it including, but not limited to travel, I hereby assume all the risks associated with the sport and agree to release and hold harmless Southwest Minnesota State University, its officers, agents, coaches and employees from any and all liability, actions, causes of actions, negligence, debts, claims or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the sport. Additionally, I understand that any previous injury or condition I have may predispose me to an increased risk of re-injury or increased risk of other injuries or conditions. Furthermore, I understand that in the event of any new injury, there may be short term and/or long term health related risks involved with continued participation in athletics, even after proper treatment or rehabilitation. I am aware of these risks, and providing the college athletic/medical staff informs me of these risks if they are not self-evident, I wish to continue my participation in intercollegiate athletics. I understand that having passed the physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the evaluator did not find a medical reason to disqualify him or her at the time of said examination. Date Signed Date Signature of Parent/Guardian (Must be signed if athlete is under 18 years of age) Date Signature of Spouse (Must be signed if athlete is married)

24 fgfgdfgfg Authorization/Consent Form for Disclosure of Protected Health Information (Form need only be completed once and remains in effect for six years or until revoked in writing) STUDENT-ATHLETE: SPORT: I hereby authorize Southwest Minnesota State Department of Intercollegiate Athletics to release my protected health information. Protected health information may include: I. Injury or illness relevant to past, present or future participation in intercollegiate athletics at the SMSU II. Information contained in my personal medical record unrelated to my participation in intercollegiate athletics at the SMSU III. Information concerning my medical status, medical condition, injuries, prognosis, diagnosis and other related personally identifiable health information, including injury reports, test results, x-rays, progress reports and any other documentation regarding my health status Authorization is granted for release of my protected health information to: I. The coaches, assistant coaches, and other athletic staff so that they may make decisions regarding my athletic ability and suitability to compete while I am a student-athlete II. My teammates so that they may be aware of limitations that I may be under while I am a student-athlete III. My parents/guardian and/or spouse for the purpose of assisting me in making healthcare decisions while I am a student-athlete IV. The student athletic trainers and other students who are participating in the provision of sports medicine healthcare to assist and participate in the provision of healthcare to me while I am a student-athlete V. Academic departments including specifically the SMSU Athletic Student Services for the purpose of making decisions regarding my ability and suitability to perform academically while I am a student-athlete VI. The NSIC Conference and National Collegiate Athletic Association for the purpose of making determination regarding my eligibility status while I am a student-athlete VII. Applicable insurance providers for the purpose of processing insurance claims while I am a student-athlete For Uses and Disclosures of Patient Protected Health Information Please Note the Following: I. SMSU Sports Medicine staff does NOT release any medical information to the press, to professional scouts, or to persons not specifically stated above. II. You may refuse to sign this authorization. Your refusal will not affect your ability to obtain treatment or payment. III. If the persons or entities that are authorized to receive the information above are not health care providers or health plans covered by federal health privacy laws, they may re-disclose the information and those laws would no longer protect the disclosed health information. IV. Once you sign this authorization, we can rely on it until you revoke it or, if you have not revoked it, until it expires. Any revocation will not be effective as to information already disclosed in reliance on the authorization. You can revoke this authorization by delivering a dated and signed letter to the Head Certified Athletic Trainer addressed to: Laura Crowell, ATR, Head Athletic Trainer, 1501 State Street, Marshall, MN V. The information authorized for release may include records which indicate the presence of a communicable or venereal disease including, but not limited to, hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome ( AIDS ) and/or mental health information. VI. Southwest Minnesota State University will not receive compensation for its use or disclosure of your protected health information. VII. This authorization will automatically expire six years from the date it is signed. Printed Name of Student-Athlete: Signature of Student-Athlete: Date: Parent Signature: (Required if athlete is under 18 years of age)

25 Sickle Cell Trait Information and Waiver Athletes submitting test results need not complete. Waiver need only be completed one time and stays in effect About Sickle Cell Trait: Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition (three million Americans). Although sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape)), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood. Sickle Cell Trait Testing: The NCAA mandates that all NCAA student-athletes have knowledge of their sickle cell trait status before they participate in any intercollegiate athletics event, including strength and conditioning training and practices. Affiliated Community Medical Centers of Marshall will perform sickle cell screening in the form of a blood test to all student-athletes wishing to be tested during their pre-participation screening. The cost of this test is the patient s responsibility. The student-athlete may also be tested by the primary care physician that is performing the pre-participation screening. Results must be submitted to the sports medicine department. Student-athletes do have the right to waive testing; or if you have been tested before, provide medical records with the results of the sickle cell testing to the sports medicine department. Please choose and CHECK one option: I, (Student Athlete Name Printed), would like to be tested for Sickle Cell Trait I, (Student Athlete Name Printed), waive my right to be tested for Sickle Cell Trait. By waiving my right to testing I understand that I must complete the Sickle Cell Trait educational training. The link to this educational video is found on the SMSU Sports Medicine webpage. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to Southwest Minnesota State University Sports Medicine personnel. I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless the State of Minnesota, Southwest Minnesota State University, its officers, employees, and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss of personal injury that might result from my non-compliance with the mandate of the NCAA and Southwest Minnesota State University Department of Intercollegiate Athletics. I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver. Student Athlete Signature: Date: Student Athlete Name Printed: Date: Sport(s): Mustang ID#: Parent/Guardian Signature (under 18) Date: Parent/Guardian Name Printed Date:

26 Sickle Cell Trait Positive Notification Form (To be completed ONLY by athletes who carry the sickle cell trait) I, affirm that I have been informed by Student-Athlete Print Name Attending Physician Print Name Date Date that I have tested positive for the following condition: 1. Sickle Cell Trait Positive Student-Athlete Initials About Sickle Cell Trait- Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse from the rapid breakdown of muscles starved of blood. Likely sickling settings include timed runs, all out exertion of any type for 2 3 continuous minutes without a rest period, intense drills and other spurts of exercise after prolonged conditioning exercises, and other extreme conditioning sessions. Common signs and symptoms of a sickle cell emergency include, but are not limited to: increased pain and weakness in the working muscles (especially the legs, buttocks, and/or low back); cramping type pain of muscles; soft, flaccid muscle tone; and/or immediate symptoms with no early warning signs. I, the undersigned, do hereby affirm that I have been informed that I am sickle cell trait positive. I further attest that the physical findings and recommendations have been discussed with me by a member of the Southwest Minnesota State University Sports Medicine Staff; and that I fully understand the recommendations and have had any and all questions answered to my satisfaction. If the testing was not provided by my private physician, I have been told to notify my private physician as soon as possible that I am sickle cell trait positive, and I agree to do so. I also have been advised to share this information with my parent or guardian. I further attest that I will notify a member of the Southwest Minnesota State University Athletic Department Staff immediately should I begin to feel weakness, cramping sensations, difficulty breathing and/or catching my breath, and/or any other signs or symptoms of distress during or after exercise without fear of repercussion. Student-Athlete Signature (if under 18 parent/guardian must also sign) Examining Physician Signature Examining Physician Print Name Parent Signature (required if athlete is under 18 years of age) Date Date Medical License Number Date

27 NCAA Banned Substances Notification Form I, affirm that I have been informed by Southwest Minnesota State Student- Athlete Print Name University athletic training personnel on this date, about NCAA Banned Substances and the NCAA Medical Exceptions Policy as it specifically pertains to the use of banned medications which are being used for legitimate medical purposes. I understand that NCAA banned medications include stimulants (i.e. Ritalin, Adderall, Vyvanse, Strattera, Focalin, Concerta, etc.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and/or like conditions, as well as beta blockers, beta-2 agonists, diuretics, peptide hormones, anabolic agents and anti-estrogens.. I attest that: Initial I AM NOT presently taking and/or have taken within the last 12 months any NCAA banned substance, including stimulant medications (i.e. Ritalin, Adderall, Vyvanse, Strattera, Focalin, Concerta, etc.), that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), or like conditions, as well as beta blockers, beta-2 agonists, diuretics, peptide hormones, anabolic agents and anti-estrogens. Initial I AM presently taking and/or have taken within the last 12 months, NCAA banned substances for legitimate medical purposes. I understand that exceptions may be granted for substances included in the following classes of banned drugs: stimulants (including those used to treat ADHD), beta blockers, beta-2 agonists, diuretics, peptide hormones, anabolic agents and antiestrogens. I agree to provide all the necessary documentation to the SMSU Athletic Training Staff. I the undersigned do hereby affirm that I understand that I am to immediately notify a member of the Southwest Minnesota State University 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. Printed Name of Student-Athlete: Signature of Student-Athlete: Printed Name of Parent: Parent Signature: (Required if athlete is under 18 years of age)

28 Concussion Disclosure Form PRIOR to completing this form you must watch the NCAA video Concussions: Don t Hide It, Report It, Take Time to Recover. I, affirm that I have been informed about Student-Athlete Print Name concussion injuries. I agree to fully disclose to the Southwest Minnesota State University Sports Medicine staff, health services staff, team physicians, and/or medical consultants engaged by them, any and all signs and symptoms of injury and/or illness, including concussions/mild traumatic brain injury about which I have become aware. I understand that any disclosed information will be utilized for the purpose of safeguarding my health as it pertains to my participation in intercollegiate athletics at Southwest Minnesota State University. I also understand that any disclosed information will be treated as confidential health care information and will only be shared with those directly involved in decisions related to my participation in Southwest Minnesota State University athletics. I verify that I have read and understand the NCAA Concussion Fact Sheet (contained in this packet) and I understand that the complete athletic concussion protocol is available in the athletic training room for my reference. I verify that have watched the NCAA video Concussions: Don't Hide It, Report It, Take Time to Recover. The link to this educational video is found on the SMSU Sports Medicine webpage. After reading the NCAA Concussion Fact Sheet and watching the video, I am aware of the following information (please initial each statement indicating awareness): 1. A concussion is a mild traumatic brain injury, which I am responsible for reporting to my athletic trainer or team physician 2. A concussion may affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. 3. I understand that I cannot see a concussion, but I might notice some of the symptoms right away. I understand that other symptoms can show up hours or days after the injury. 4. If I suspect a teammate has a concussion, I am responsible for reporting the injury to my athletic trainer or team physician. 5. I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms. 6. I understand that after a concussion the brain needs time to heal. I understand that I am much more likely to have a repeat concussion if I return to play before my symptoms resolve. 7. I understand that in rare cases, repeat concussions can cause permanent brain damage, and even death. Printed Name of Student-Athlete: Signature of Student-Athlete: Date Printed Name of Parent: Parent Signature: Date (Required if athlete is under 18 years of age)