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6034a - Instruction for Parents and Concussed Athlete


Home Instructions for Parents & Concussed Athlete

Athlete _______________________________________________ Date of Injury _______________ Sport/Activity __________________

Parent/Guardian Name ____________________________________________________________ Phone _________________________

1. Your son/daughter is suspected of having sustained a concussion. Today, the following signs and

symptoms of a concussion were observed:

2. The following steps were taken for your son/daughter by coaches or school personnel:

3. The school directs your son/daughter to be evaluated by an appropriate licensed healthcare professional

(LHCP), i.e. MD, DO, Neuropsychologist, or Athletic Trainer, AND your son/daughter will need written

clearance from a LHCP, and written clearance from you ‐ the parents/guardian, before your son/daughter

can be allowed to return to activity or athletic participation (LB260 Nebraska Concussion Awareness Act, July 2012).

Recommendations provided to: _________________________________________ Date: ___________ Time: __________

Recommendations provided by: _________________________________________ Phone #: ________________________

Please Review Reverse Side for Additional Information Regarding Concussions

SIGNS observed by Coach/others SYMPTOMS reported by Athlete

 Loss of Consciousness  Headache

 Seizure activity  Nausea, vomiting

 Can't recall events prior to injury  Dizziness or Balance Problems

 Can't recall events after injury  Difficulty concentrating

 Disoriented (as to self, place, time)  Feeling sluggish or "slowed‐down"

 Confusion (as to injury, plays)  Feeling "in a fog" or "foggy"

 Moves clumsily, unsteady  Difficulty remembering things

 Appears dazed, stunned  Double or Blurred Vision

 Memory Problems  Bothered by light or noise

 Answers questions slowly  Drowsiness

 Asks same question repeatedly  Fatigue

 Vacant stare, glassy eyed  Difficulty falling asleep

 Easily distracted  Sleeping less than usual

 More emotional  Sleeping more than usual

 Behavior/Personality changes  Nervousness

 Unusually Irritable  Sadness

 Removed from participation

 Checked for a neck/spinal injury

 Checked if immediate emergency care was needed

 Assessed orientation, memory, concentration, and balance

 Restricted from any further participation and exertional activities

 Continued to be observed and monitored by coaches and school staff

 Informed them of the need to be evaluated by appropriate licensed

healthcare professional (MD, DO, Athletic Trainer, Neuropsychologist)

Observing and Monitoring Signs & Symptoms of a Concussion

In some instances, Signs & Symptoms of a concussion may not become apparent until several hours or even days after the

injury. Therefore, your son/daughter should be monitored closely over time, and checked for any of Signs and Symptoms

listed on the front side of this form. A good guideline is to note signs/symptoms that worsen, and behaviors that seem to

represent a change in your son/daughter. Please be especially observant for Signs and Symptoms listed below. The

following indicate the need to report immediately to the nearest emergency department for medical care, or in an

emergency, to activate Emergency Medical Services (EMS) by dialing 911:

1. Headaches that increase in intensity

2. Vomiting

3. Decreased or irregular pulse OR respiration

4. Unequal, dilated, unreactive pupils

5. Slurred speech

6. Seizure activity

7. Changes in level of consciousness, very drowsy, difficulty awakening, or losing consciousness

8. Can’t recognize people or places, or becomes increasingly confused

If you have any question or concern about the signs or symptoms you are observing, contact your family physician for

instructions, or seek medical attention at the closest emergency department. Otherwise, you can follow the instructions

outlined below.

Returning to School

In some circumstances, the following recommendations may be indicated by the licensed healthcare professional (LHCP)

treating your son/daughter, with supportive accommodations provided by school personnel.

1. No school; shortened school day; time restriction on school day.

2. Shortened class time; limit work on computer, focused reading, or analytical problem solving; withhold from PE.

3. Extra time to complete coursework/assignments/tests; assistance with instruction.

4. Reduced homework load; time restriction on homework.

5. Refrain from significant test taking, or standardized testing.

6. Frequent rest breaks during day as needed.

7. Consider Individualized Educational Plan (IEP) or 540 Plan if recovery is likely to be prolonged.

Symptoms are to be monitored regularly during recovery. Gradually increase school activity when symptoms begin to

subside/decrease. Decrease school activity if symptoms increase or return at any time.

Returning to Sport

Anytime an athlete is removed from activity due to a suspected concussion, they must follow these steps for returning to sports


1. Evaluation by an appropriate licensed healthcare professional (LHCP), i.e. MD/DO, Athletic Trainer, or Neuropsychologist.

2. Athlete must first be symptom‐free at rest, then remain symptom‐free during physical and mental exertion.

3. Written clearance from designated LHCP, and written clearance from parent/guardian.

4. When available, Post‐Injury Neurocognitive Test Scores (ImPACT) return to normal (baseline).

5. Follow and complete “Stepwise Progressive Return to Play Program” while remaining symptom‐free.

Stepwise Progressive Return to Play Program

After Step 1, allow 24‐48 hours is to elapse between steps, as directed by your LHCP.

1. Symptom‐free at rest. Rest ‐ no physical or mentally taxing activity;

2. Light aerobic, low level activity; no weight‐lifting or resistance training;

3. Sport/Position specific condition drills, light‐to‐moderate weight‐lifting and resistance training.

4. Restricted practices, non‐contact, non‐live practice drills.

5. Full, unrestricted practices, live

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