Board of Directors Meeting — Agenda Item Date of BOD Meeting: 2/9/23 ‘Submitted by: @FHSAA Staff QBOD OCommittee Oind. For which Committee: []Finance [|Governance [JOperatons [Appeals Item is for: [¥] Action []Discussion [information only For General Business Meeting Item is: [¥ action [_Jpiscussion formation only Data Source: FHSAA Bylaw 9.7; 9.7.3 (Le. FHSAA Bylaw/Policy, Fla, Statute, etc.) Topic: A Pre-Participation Examination (PPE) is required by Florida Statute 1002,20(17X), 1006.20(2)¢) and FHSAA Bylaw 9.7 to ensure safe participation in sports by student-athletes, | Spoctially: Submission ofthe full BL2 to member schools, This request i to adopt the updated FHSAA FL2 form (four wal pages) recommended by the SMAC withthe exception of removing questions 30-33. Furthermore, only the fourth page ofthe EL2 (the medical clgibility form) willbe submitted to the member school. The qualified healthcare practitioner performing the examination or parentguardian will keep the medal history and/or examination Forms (pages 1-3). Detailed Information rie ststament-background, observations st te): ‘The submission of the full FHSAA EL2 Form to member schools has created concerns and questions from parents, school district administrators, school board members, and coaches regarding the health privacy of student-athletes. While the Association understands it is vital to protect the privacy of all student-athletes, we must address the important role medical history plays in a pre-participation physical examination. Therefore, this recommendation [provides pertinent medical history to the qualified health care practitioner and gives schools the medical authorization necessary for allowing athletic participation, while protecting the privacy of the student-athlete. Provide attachment(s) a5 epplicable Executive Director Recommendation: The Executive Director endorses adopting the updated EL2 form (as amended above in the topic section) and requiring only the fourth page (Medical Eligibility) to be collected by the member school. Pages 1-3 of the EL2 will remain with the qualified health care practitioner performing the examination or parent/guardian of the student-athlete. Rationale & Impa ‘The intent of this proposal is to provide an updated PPE form which protects a student-athlete’s privacy while including pertinent medical information a health care provider at a member school would need access to. Alternative to Recommendation: Printed Name of individual/Committes Submiting Item Signature Craig Damon G J Printed Name of FHSAA Staff Member Presenting Item ‘SignatureTgETC Te eae SoTL PAGES TO BE KEPT BY QUALIFIED HEALTH CARE PRACTITIONER OR PARENT/GUARDIANOVE ORIDA This medical history form should be retained by the healthcare provider andlor parent. This form is valid for 365 calendar days from the date signed below. HISTORY FORM ‘Student Information (to be completed by student and parent) Saude frame Sex asiped ebiek_Age_Datw ators __f_. Sehost: Grae n shook __ Spore Heme ees oy Heme phone) Nee of PrenGuardn Eat enon to conten et of mera Ratti soe ‘ergo concep) Werk phone (_). Over phone: Fama eee prone: Cie ee shone_) Tis past and current media conditions Have you ever had scgery?_ yes, please Stl srl procedures and dates: Medicines and suplemenes, Pease lis all curent prescription medians, yer-thecountr medicines and supplements (herbal and ntitonl) Do you have any lrg? yes, pease Ia al of your ergs la medicines, poles, food secs) Patient Heath Questionaire version 4 (PH-4) (re he pst wo weeks, hw fen hoe you Ben tere by oy of he owing probes? (Cre rose ‘Noeatall Several ys Over aloft Neary even Feng nervous aout oF 3 onedge £ ' e ‘Nor beng le 9 op oF Nos b ° 1 2 3 ie rres or eS oing tings ° i 2 3 ean down depressed or D fi 2 3 hopeless a Cae onion HEART HEATH GUETIONS ABOUT YOU ip pr ert end em. ye | no (ex) Ye | No | detsorea derwon ‘oar ocr tou we oi Wh ont Tan acer ow raped at oryourbar! For cam ® | sesrncndepihy ar aeortoyghy SEO? ass proer er ed rad or prcpn ors . | ora tghated ord sor f eh a your a eres ese 3 bojestoe lies are Doe To] wea {HEART HEALTH QUESTIONS ABOUT YOU Yer | No | Hein HALT QUESTIONS ABOUT YOUR FARE Ye [he hs Sir mater rev did ar pols” an reaped orcad ate ts re 39 ig ve yu er psd ot or ry ped ou da or [bots rt ave alin ch ve yore ol corti x pres in our rs yo ms 12 | epeveetatararaomyoqty ARVO erg QT pone LOTS. seers cece ‘Port GT seams SOT) Badass er anchlnerge Jatin enredar cyte CYT 1 | Bower artery ast os bw re Ta | Heseyne nro mio ptr ran ed oar en igure! rene 8 Hors dcr er sosyor dary ety ba rene “Tsar net conered ld wet allecles ar competeQF ORIDA This medical history form should be retained by the healthcare provider andlor parent," This form is valid for 365 calendar days from the date signed below. Studentathlete name: Date of births 1 Schoot TONE ANOJONTOUETINS ve (HEDICAL QUESTIONS covet) va [we 4 | Hove es ert sre acre? 72h | Boy wry bet our wee ig | dvr eer estos mace Rome Braeden ay | Aros eng rte eyore ened tyrone | cued orto ma pce mig 16 | Doyovtve bone muce mee erone iy Hatred sa__| Arora peal to yoo ara ood = HDA. QUSTION, % | Hav) eri a ryan ‘Doyee ooh whens rhe ay beg goer se ora roe pote ou wth ‘rey ings ine ny est or le a7 here oyes tne yom or ate panera aH genoa gonwe deg hepa or metic ophectco eens rwsa sound hatin eomamer en! ve you cera amines a ig Zana nor oye ordourzoecnin your Sly ve cic waar “This form ipo cnaered i as a econ ar capes Patipason in high schoo sport isnot without risk. The studen athlete and parenlguardan acknowledge truhll answers to the above question allows fr 3 ‘rained ein to tues the rail sudo tle spit ik etors ssceated with sport Fla npr and death. Fria Stee $1006.20, aque 3 ‘radon canto fran serach shes tea to succes complete» preparidpston evalumon asthe Ss step of wy prevention. This preparicpaton ‘medical evluzton stall be completed each year before prticpating in mrschlase tle competion or engaging in any praca, rout, workout cONBCONNg. (Or othar phys acy, ncluingactwcer at occur Outside of he school year. ‘We hereby sat, to thebestof our knowlege, du our answers othe above quesdons are complete and correct. a adon othe routne med eration require by §100620, Frida Sutues and FHSAA Bylaw 97, we understand an acknowledge that we are herby asd that the stdene should undergo 2 ‘ariovselr sssessnee whieh may Inde sch dagrosse tet as eleerocardlogram (ECG), echocardiogram (ECHO) andlor eaco sres test The FHSAA Sports Masine Adisory Comsmioe strongly reconmends 3 medical evalition with our heath ae provider fr Fk ators of aden cardiac ares which may incide the spocl tet nod above, suerte Nae PareetGardan Name rind) FaeniGurdan Sipsare Phreuardn None (Pred Sen Aer Sure [Princ ParerdGarden Spence ested ram © 2019 kenerten kad of Far Pyles, American casey of Peds, rnc Coleg of prt Md, eercan Medal Set for Sart Mes, ‘Area Othpae Soi for Sart edn, and srerianOtepathie Savery prs Mee Permsen ented orp or roca, aaa urbe eines(7 forbs 0) This evaluation form shouldbe Tecaned by te healthcare provider andior porent. [me “his assessment fs valid for 365 calendar days from the date signed below Physical Examination Form: Student-athlete name: Date of birth JJ ‘School: PHYSICIAN REMINDERS Consider addons questions on moresensite sues * Do you feletresed outor unders tof reser) ‘| » Do you ev fel ad, hopelesr, dress, or andour? Do you fea af at your home or esidance? During the fast 30 days. did you use cheweg tobacco, suf or dip . = Have you ever taken anabolic trode or used any other performance ‘Do yu drnkslcohol or us any other drug? eerucs sie 7 ve you eve ake any wpplamens © help you gan or lose weight lortmdrove jour performance! Vent conpleon of FHSAA E12 Meal Hiory orm pgs | and 2, row there medi sory responses apart of your asessmene. Grower storispmptom quesions include (4-13 of History Form). (checkbox if completo) Ee Heike Weis oe) Vision: R20) L20) Corrects GY aN Senne Sa ‘Aepenrice + Martin gros (ophoscoos, Niarched pba, pects escenario hyped mop, mir va roan [MVP] and sor nsec) yon, are nove and ost -Papleege Heng mph nodes Heat Murmurs (wsaeion rand sciaton sine and # Vals manever ‘borer fen Flerpes simplex views (HSV) lesons pee of metis-esant Sapyocces aureus (MRSA) or na corprs Newroegea SESE SEG Nose Back ow aed forearm Wi, hd, ad agers Hip and eh Lega ae Footindiaer Fncion + Double eg sunt se, sigleg sunt wat and box drop or sep drop tas * consi eacwocgy (ECG), chocarogphy (ECHO) rfrato rologe or sbormal rac Hor or eamieon Gs ay combo rec. The PSUS Mere ay Cnn (A) ogy ened os it ere «mae eran wih your heh fa fs fen a est tc mye sereaopan [Name ofheseare proesion (int ore ate of oa Aro Prone Ema Signore of heatheareprfesion Cree Leese ‘eon ican att cs hin kal ae, in ag a das tan edly para Ns, MeO [espn eainndanertan Onan Keay fesse Porc pel bri homme el pos Ms etoUL Rre Te ae I PAGE SUBMITTED TO SCHOOLWi FLORIDA enn PREPARTEATION SICAL EVALUATION ge 4 4) aed 623 SUBMIT THIS MEDICAL ELIGIBILITY FORM TO THE SCHOOL ~— "his cnptted frm stab pt fle shel TS fr val for 365 cl dys rm he eed since eon MEDICAL ELIGIBILITY FORM Student Information (tobe completed by student or parent) > Seadene name: Sex asigned a Be Age Date ofits seo Gradein schoot__ Spores Home sree: ony. Home phone (_) Name of ParentiGuardan: Ema Person to cotactin ase of emergency Rebtionship to sudene Emorgecy eonect ell phone: (__) Werk phone:(__) ‘Oxrer phone: (_) Family beathare provider: Cryisate: Office phone:(_) 1 Medea ge fr pons wot resriion 1 Medel lg fr spores wthou reson wth reammendaon for unher eliason ar meamen oe adda set f ees} 1 Milly elle fr oly coin spor ited blows 12 Neimedealy hye foray spans Recommendation: (ise addtional het, nce) "here cory that Ihave examined the abovesamel seident athlete using the FHSAA EL2 reparcaion Phyl rluon and have provided the conclusions lstd above. A copy of the a has been retained and can be acessd by the parent a requested. Any nury or other medial condos hat arise aer the dete ofthis metal dearance shoul be properly evalunted,agnosed and eeated by an appropiate healthcare pofessondl prior to Parcipton in activites Nama of heath cre profesional rin or yp) Ades Phone Spaure ofheatheareprofesonse Credercin eens te [Dy Sticks bri tere serene mesa sory to Hare rtd aripson in roe Samp red compete sports Mediation: (use addtional sheet, i necessary) ust: Relevant medical history tobe reviewed by tls trainerteam physlan: exp below, a edition sheets meesry [Allergies © Asthma (i Cardiae/Meare.[} Concussion [Diabetes] Heat liness 7 Orthopedic Surgial history 1 Sie eel walt "Other Ela Satire of dene Dave Sgntur of arentGuardan pee ft ey th al a gh no id am cn rac unannealed ne sede SRR SS a tg et cine en ear “Ths form not considered valé lee al scons are complete sete sin Key fy Pp, Atanas of i, Ane lige of rt Me, Anan ely fr ats Aes, eee ‘ity bene, tats ape eof rs ea ee eM nee nan pes sh awe[FELORIDA PAGE SUBMITTED TO SCHOOL IF APPLICABLE® @ ‘FLORIDA PREPATIOPATIONPAYBAL EVALUATION plement) ed 6/23 SUBMIT THIS MEDICAL ELIBUITY FORM TO THE SCHOOL fe ‘This completed fom shall be kep on file bythe stbec-This form I veld for 365 clender Gays fom the dated signature below This form is only used, or requested, ifa student-athlete hos ben refered for adetionol evaluation, prior to fll medical clearance. MEDICAL ELIGIBILITY FORM - Referred Provider Form ‘Student Information (tobe completed by student or parent) Stent fll name: Sec assigned at bite ‘Age __Date fires. Sehoot Gradein schoot__ Sports) Home ade: ry Home phone: (__) Name ofParenGuardan Esa: Person to contact in ae of enerzeny Rehiondhp wo saudene merpeney contact cll phone: (_) Work phones) (Other phone: _ Fay healthcare prover: _CryScate fice phone: (_) Referred for Diagnosis 1 rey cy the evaludcn an essessment fo whieh ts ude hte wos refered hos ben conde by mye occan under my diet supeison wth the eocisoradoamentd below 1 Medel ele fora pons wihou resrion a ofthe dace sped blow 1 Medel ge foragers wihour resricin ater conlaton of th folowing tauren pln toon sheet recs) 1 Medea lee or ny aan sortase (Nate elgble for any spars parcpaen Further Recommendavons: (ie addtional sheet, neces) Name of heats prefesson (pin or 9p: Dae Adee: Fore Siepsture of heakheare profesions Credenis Lcense