Policy Details

5141.7 FORM 2 Student and Parent Concussion Informed Consent Form

# 5141.7
Form 2

Litchfield Public Schools

Student and Parent Concussion Informed Consent Form


This consent form was developed to provide students and parents with current and relevant information regarding concussions and to comply with Connecticut General Statutes (C.G.S.) Chapter 163, Section 149b: Concussions: Training courses for coaches. Education plan. Informed consent form. Development or approval by the State Board of Education and Section 10-149c: Student athletes and concussions. Removal from athletic activities. Notification of parent or legal guardian. Revocation of coaching permit.

What is a Concussion?

National Athletic Trainers Association (NATA) - A concussion is a "trauma induced alteration in mental status that may or may not involve loss of consciousness."

Centers for Disease Control and Prevention (CDC) - "A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth." -CDC, Heads Up: Concussion http://www.cdc.gov/headsup/basics/concussion_whatis.html

Even a "ding," "getting your bell rung," or what seems to be mild bump or blow to the head can be serious" -CDC, Heads Up: Concussion Fact Sheet for Coaches http://www.cdc.gov/concussion/HeadsUp/pdf/Fact_Sheet_Coaches-a.pdf

Section 1. Concussion Education Plan Summary

The Concussion Education Plan and Guidelines for Connecticut Schools was approved by the Connecticut State Board of Education in January 2015. Below is an outline of the requirements of the Plan. The complete document is accessible on the CSDE Web site: http://www.sde.ct.gov/sde/cwp/view.asp?a=2663&q=335572

State law requires that each local and regional board of education must approve and then implement a concussion education plan by using written materials, online training or videos, or in-person training that addresses, at a minimum the following:

  1. The recognition of signs or symptoms of concussion.
  2. The means of obtaining proper medical treatment for a person suspected of sustaining a concussion.
  3. The nature and risks of concussions, including the danger of continuing to engage in athletic activity after sustaining a concussion.
  4. The proper procedures for allowing a student athlete who has sustained a concussion to return to athletic activity.
  5. Current best practices in the prevention and treatment of a concussion.

Section 2. Signs and Symptoms of a Concussion: Overview

A concussion should be suspected if any one or more of the following signs or symptoms are present, or if the coach/evaluator is unsure, following an impact or suspected impact as described in the CDC definition above.

Signs of a concussion may include (i.e. what the athlete displays/looks like to an observer):


Trouble resting/getting comfortable

Lack of concentration

Slow response/drowsiness

Incoherent/ slurred speech

Slow/clumsy movements

Loses consciousness

Amnesia/memory problems

Acts silly/combative/aggressive

Repeatedly ask same questions

Dazed appearance


Constant attempts to return to play

Constant motion

Disproportionate/inappropriate reactions

Balance problems

Symptoms of a concussion may include (i.e. what the athlete reports):

Headache or dizziness

Nausea or vomiting

Blurred or double vision

Oversensitivity to sound/light/touch

Ringing in ears

Feeling foggy or groggy

State law requires that a coach MUST immediately remove a student-athlete from participating in any intramural or interscholastic athletic activity who: a) is observed to exhibit signs, symptoms or behaviors consistent with a concussion following a suspected blow to the head or body, or b) is diagnosed with a concussion, regardless of when such concussion or head injury may have occurred. Upon removal of the athlete, a qualified school employee must notify the parent or legal guardian within 24 hours that the student athlete has exhibited signs and symptoms of a concussion.

Section 3. Return to Play (RTP) Protocol Overview

Currently, it is impossible to accurately predict how long an individual's concussion will last. There must be full recovery before a student-athlete is allowed to resume participating in athletic activity. Connecticut law now requires that no athlete may resume participation until they have received written medical clearance from a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.

Concussion Management Requirements:

1.No athlete SHALL return to participation in the athletic activity on the same day of concussion.

2.If there is any loss of consciousness, vomiting or seizures, the athlete MUST be immediately transported to the hospital.

3.Close observation of an athlete MUST continue following a concussion. The athlete should be monitored for an appropriate amount of time following the injury to ensure that there is no worsening/escalation of symptoms.

4.Any athlete with signs or symptoms related to a concussion MUST be evaluated by a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.

5.The athlete MUST obtain an initial written clearance from one of the licensed health care professionals identified above directing her/him into a well-defined RTP stepped protocol similar to the one outlined below. If at any time signs or symptoms return during the RTP progression, the athlete should cease activity*.

6.After the RTP protocol has been successfully administered (no longer exhibits any signs or symptoms or behaviors consistent with concussions), final written medical clearance is required by one of the licensed health care professionals identified above for the athlete to fully return to unrestricted participation in practices and competitions.

Medical Clearance RTP protocol (Recommended one full day between steps)

Rehabilitation stage

Functional exercise at each stage of rehabilitation

Objective of each stage

1. No activity

Complete physical and cognitive rest until asymptomatic. School may need to be modified.


2. Light aerobic exercise

Walking, swimming or stationary cycling maintaining

intensity ,<70% of maximal exertion; no resistance training

Increase Heart Rate

3. Sport specific exercise No contact

Skating drills in ice hockey, running drills in soccer; no head impact activities

Add Movement

4. Non-contact sport drills

Progression to more complex training drills, ie. passing drills in football and ice hockey; may start progressive resistance training

Exercise, coordination and cognitive load

5. Full contact sport drills

Following final medical clearance, participate in normal training activities

Restore confidence and assess functional skills by coaching staff

6.Full activity

No restrictions

Return to full athletic participation

* If at any time signs or symptoms should worsen during the RTP progression the athlete should stop activity that day. If the athlete's symptoms are gone the next day, she/he may resume the RTP progression at the last step completed in which no symptoms were present. If symptoms return and don't resolve, the athlete should be referred back to her/his medical provider.

Section 4. Local/Regional Board of Education Policies Regarding Concussions

****** Attach local or regional board of education concussion policies ******

I have read and understand this document the "Student and Parent Concussion Informed Consent Form" and understand the severities associated with concussions and the need for immediate treatment of such injuries.

Student name: ______________________________________ Date ______ _ Signature ____________________________

(Print Name)

I authorize my child to participate in ____________________________ __ for school year ________________________


Parent/Guardian name: _________________________________ Date _______ Signature__________________________

(Print Name)


1.NFHS. Concussions. 2008 NFHS Sports Medicine Handbook (Third Edition). 2008: 77-82.



2.Centers for Disease Control and Prevention. Heads Up: Concussion in High School Sports. http://www.cdc.gov/NCIPC/tbi/Coaches_Tool_Kit.htm.

3.CIAC Concussion Central - http://concussioncentral.ciacsports.com/


Centers for Disease Control and Prevention. Injury Prevention & Control: Traumatic Brain Injury. Retrieved on June 16, 2010.


Centers for Disease Control and Prevention. Heads Up: Concussion in High School Sports Guide for Coaches. Retrieved on June 16, 2014.

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