Figure 5

Student-Athlete Date of injury

Preparing World-Class Students

Sport Parent/guardian name Home Phone____________________________

Notification of Probable Head Injury Dear Parent:

Based on our observations and/or incident described below, we believe your son/daughter exhibited signs and . Since your son/ daughter has not symptoms of a concussion while participating in been evaluated by a physician at school, it is important that you seek a physicians care as soon as possible.

It is important to recognize that blows to the head can cause a variety of injuries other than concussions (e.g., neck injuries, more serious brain injuries). Please be sure to see your doctor as soon as possible for any other medical concerns. Description of Incident! Injury:

When to Seek Care Urgently. If you observe any of the following signs, call your doctor or go to your ememency department immediately. Very drowsy, cant be awakened Cant recognize people or places Headaches that worsen Increasing confusion Repeated vomiting Seizures
Neck pain Unusual behavior change Slurred speech Significant irritability Weakness/numbness in arms/legs Less responsive than usual

Common Signs & Symptoms. It is common for a student with a concussion to have one or many symptoms.
ysical Headache Nausea/Vomiting Visual Problems Fatigue/ Feeling tired Sensitivity to light! noise Numbness/Tingling Cognitive Feeling mentally foggy Feeling slowed down Difficulty remembering Difficulty concentrating Emotional Irritability Sadness More emotional Nervousness Sleep Drowsiness Sleeping less than usual Sleeping more than usual Trouble falling asleep

3
LI

Dizziness Balance Problems

Please feel free to contact me if you have any questions. I can be reached at:

Employee Name and Title

Date

TO BE COMPLETED BY THE AUTHORIZED HEALTH CARE PROVIDER:

Name: Diagnosis: Signature

Date:

Please be advised that your son/daughter will not be allowed to return to play until they have no symptoms and have been cleared in writing by an authorized health care provider (physician, neuropsychologist, nurse practitioner, physicians assistant) for this type of injury. Distribution: _Parent AD _School Health Room

Figure 6

MARYLAND STATE DEPARTMENT OF

Student-Athlete_________________________________ Date of injury Todays Date Sport

EDUCATION
(.I +]1

irrLvl r

iir

Medical Clearance for Gradual Return to Sports Participation Following Concussion

To be completed by the Licensed Health Care Provider The above-named student-athlete sustained a concussion. The purpose of this form is to provide initial medical clearance before starting the Gradual Return to Sports Participation. Criteria for Medical Clearance for Gradual Return to Play (Check each) The student-athlete must meet all of these criteria to receive medical clearance. 1. No symptoms at rest/ no medication use to manage symptoms (e.g., headaches) 2. No return of symptoms with typical physical and cognitive activities of daily living 3. Neurocognitive functioning at typical baseline 4. Normal balance and coordination 5. No other medical/ neurological complaints! findings Detailed Guidance 1. Symptom checklist: None of these symptoms should be present. Assessment of symptoms should be broader than athlete report alone. Also consider observational reports from parents, teachers, others.
Physical Headaches Nausea Fatigue Visual problems Sensitivity to light Sensitivity to noise Numbness/ tingling Vomiting Cognitive Feeling mentally foggy Problems concentrating Problems remembering Feeling more slowed down Emotional Irritability Sadness Feeling more emotional Nervousness Sleep Drowsiness Sleeping more than usual Sleeping less than usual Trouble falling asleep

Balance Problems Dizziness

2. Exertional Assessment (Check: The student-athlete exhibits no evidence of return of symptoms with: Cognitive activity: concentration on school tasks, home activities (e.g. TV, computer, pleasure reading) - Physical activity: walking, climbing stairs, activities of daily living, endurance across the day 3. Neurocognitive Functioning (Check): The students cognitive functioning has been determined to have returned to its typical pre-injury level by one or more of the following: Appropriate neurocognitive testing Reports of appropriate school performance/ home functioning (concentration, memory, speed) in the absence of symptoms listed above

4. Balance & Coordination Assessment (Check): Student-athlete is able to successfully perform: - Romberg Test OR SCAT2 (Double leg, single leg, tandem stance, 20 secs, no deviations fr proper stance) 5 successive Finger-to-Nose repetitions < 4 sec I certify that: I am a Licensed Health Care Provider with training in concussion evaluation and management in accordance with current medical evidence (2010 AAP Sport-Related Concussion in Children and Adolescents, 2008 Zurich Concussion in Sport Group Consensus). The above-named student-athlete has met all the above criteria for medical clearance for his/her recent concussion, and as of this date is ready to return to a progressive Gradual Return to Sports Part icipation program (typically lasting minimum of 5 days).

Provider Name Signatu Distribution: _Parent _AD _School Health Room Date:

A MONTGOMERY (\CouNrY PUBLIC

Student Sport

Date of Injury

\#

SCHOOLS

Practice

Game

Parent Notification of PobIeHead Injury! Medical Clearance Formby Authorized Health Care Provide Description of I nddentllnjury:

A student who has suffered a concussion must obtain written clearance from an authorized health care provider in order to return to play. Based on our observations we believe your son/daughter exhibited signs and symptoms of a concussion while participating on the date/activity indicated above. It is important to monitor head injuries. A persons condition can rapidly deteriorate many hours after the injury. Also, blows to the head can cause a variety of injuries other than concussions (e.g., neck injuries, more serious brain injuries). Please be sure to see your doctor as soon as possible for any other medical concerns.

When to Seek Care Urgently. If you observe My of the following signs, call your doctor or go to your
emergency department immediately. Headaches that worsen Seizures Neck pain Unusual behavior change Very drowsy, cant be awakened Repeated vomiting Slurred speech Significant irritability Cant recognize people or places Increasing confusion Weakness/numbness in arms/legs Less responsive than usual

Common 9gis & Symptoms It is common for a student with a concussion to have one or many symptoms. Em ot ional seep Cogn itive Phyl
Headache NausealVomiting Dizziness Balance Problems Visual Problems Fatigue! Feeling tired Sensitivity to light! noise Numbness/Tingling Feeling mentally foggy Feeling slowed down Difficulty remembering Difficulty concentrating Irritability Sadness More emotional Nervousness Drowsiness Sleeping less than usual Sleeping more than usual Trouble falling asleep

Additional concussion information can beaaed through the PSSAA webteatjwww.M PSSAA.orgl
Please feel free to contact me if you have any questions. I can be reached at:

Employee Name and Title

Date

TO BE COMPLETED BY THE AUTHORIZED HEALTH CARE PROVIDER (Liciphyaan, clifial physicians assistant under the xpervision of a licensed physician, or clifiaJ nurse practitioner)
Office Stamp / Phone

Providers Name: Student examined on

Date

Signature: Student may return to play on

Date

Concussion: 0 yes 0 no

If not a concussion, Diagnosis:

Special Instructions/limitations:

Office of the Superintendent of Schools MONTGOMERY COUNTY PUBLIC SCHOOLS Rockville, Maryland August 24, 2012 MEMORANDUM To: From Subject: Question Mr. Durso referred to Mr. Hearns (Mr. Thomas Hearn, community member) testimony. He asked about the statement that the August 2010 state Concussion policies "do not require notice to the school nurse or to the principals, which appears to be required under current MCPS regulations." Response The Montgomery County Public Schools (MCPS) form, Parent Notification of Possible Head Injury/Medical Clearance Form by Authorized Health Care Provider, does not include a "copy to" line for school nurses and principals. However, as the title of the form indicates, at the time in which the completion of the form is initiated, it is not known for certain whether the student has suffered a concussion. Instead, the form indicates that the student has exhibited at least one sign or symptom consistent with a concussion. The medical doctor or health care provider subsequently makes the determination on how serious the injury is, including whether the injury was a concussion. MCPS Regulation EBH-RA, Reporting Student Accidents, requires that athletic coaches submit MCPS Form 525-2: Student Accident Report, when students suffer particular types of injuries, including head injuries. Once it is determined that a concussion has occurred, the coach must submit Form 525-2, Student Accident Report, to the school principal. Question Mr. Durso asked about recommendations (made by Mr. Thomas Hearn, community member) to limit the number of full contact practices per week in football and eliminate repetitive header drills in soccer. Members of the Board of Education Joshua P Starr, Superintendent of Schools Head Injury Procedures in Athletics (07-3-12-0l)

Members of the Board of Education

August 24, 2012

Response

Mr. Hearns rationale for limiting contact appears to be based on full-contact limitations imposed by the National Football League (NFL) and the Ivy League. The NFL reached a collective bargaining agreement with the NFL Players Association prior to the 2011 season that limits fullcontact practices to one per week once the regular season commences (full contact is allowed every day until the regular season begins). For the 2011 season, the Ivy League limited fullcontact practices by member schools to two per week during the regular season, a sixty-percent reduction from what the National Collegiate Athletic Association (NCAA) allows member schools. No other Division 1, 2, or 3 college conferences have established full-contact practice limitations. The age, size, speed, skills, length of season, and level of experience differ significantly for high school players than college or professional players. Regulations that govern high school interscholastic athletics are developed by the National Federation of High Schools (NFHS), which include nationwide representation and a Medicine Advisory Committee comprising medical professionals and administrators across the country. There are no high schools in the Washington, DC metropolitan area or high schools that belong to the Maryland Public Secondary Schools Athletic Association (MPSSAA) that have specific full-contact practice limitations. The "repetitive header drills" that Mr. Hearn refers to involve performing soccer drills in which players practice "headers" in repetitive fashion. It is imperative that soccer teams practice proper heading technique for both safety and competitive purposes. Similar to many other drills in other sports, excessive drilling in a particular area over a sustained period of time may lead to injury. If you have questions, please contact Mr. Larry A. Bowers, chief operating officer, at 301-279-3626 or Dr. William G. Beattie, director, Systemwide Athletics, at 301-279-3144. JPS :wgb Copy to: Mr. Bowers Mr. Edwards Dr. Beattie