IMPACT Testing Consent Form

IMPACT Testing Consent Form

You may also find a MS Word form on the Sports Medicine page.


Crestwood School District:

Consent for Administration of ImPACT Concussion Testing

 

 

I give my permission for (Print Name of Child) _____________________,  (Child’s Date of Birth)__________________  to have a baseline and post-concussion ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) administeredby Crestwood School District Athletic Training. I understand that my child may need to be tested more than once, depending upon the results of the test, as compared to my child’s baseline test, which is on file at Crestwood School District.

Crestwood School District may release the ImPACT results to child’s primary care physician, neurologist or other treating physician or care provider if necessary. I understand that general information about the test data may be provided to my child’s guidance counselor and teachers for the purposes of providing temporary academic modifications if necessary.

I also have read the reverse side of this sheet and I fully understand the reason for the ImPACT testing and the risk my child is at during athletic participation to sustain a concussion.

 

I understand that my son/daughter should be cleared by a neurologist or physician before returning to athletics or activity following a concussion.

 

Name of Parent or Guardian (Print): _____________________________________

 

Signature of Parent or Guardian: ________________________________________

 

Date: _____________________

 

Name of Student athlete (Print): ________________________________________

 

 

Signature of Student Athlete:___________________________________________

 

 

Date:_______________________

Information on Concussions and ImPACT Testing

Concussion:

What is a concussion?

A concussion is defined as a series of complex pathophysiological process affecting the brain by traumatic biomechanical forces. According to the Center of Disease Control (CDC), “ traumatic brain injury can cause a wide range of short or long term changes affecting thinking, sensation, language , or emotions. “ These changes may lead to problems with memory and communications, personality changes, as well as occasional depression.  It can result in a variety of symptoms and often does not involve loss of consciousness.  Even a "ding," or what seems to be a mild bump or blow to the head can result in a concussion.

 

What is Second Impact Syndrome?

Second Impact Syndrome, is when you experience two concussions within a short amount of time. This could be a life changing experience if this were to happen. Second impact injury can result within a matter of days or weeks, or it can occur in the same game or competition if the athlete isn’t removed and treated after the first concussion. Neither impact has to be severe for second impact syndrome to occur. Symptoms usually occur immediately following the second impact and progress rapidly. Common symptoms include: dilated pupils, loss of eye movement, unconsciousness, respiratory failure, or death.

 

ImPACT Testing:

ImPACT Concussion testing is a computer-based test that objectively measures the function of the brain, focusing on attention, memory, processing speed and reaction time.

 

Who takes int ImPACT test?

            Every student athlete participating in sports at Crestwood that has a risk of head injury while participating in their respective sport. The ImPACT test is valid for 2 years, therefore it will be given to student- athletes in 7th, 9th, and 11th grade, as well as any athlete who sustained a concussion the previous year or is new to athletic participation at Crestwood School District.  (for the 2014-2015 school year, every athlete will be administered the ImPACT test)

 

 Why do we want you tested?

The ImPACT test is one of the most effective ways to get an objective measurement of your child’s “normal” brain functions (reaction time and memory) in case there is an incident where they may have a concussion. Is an incident occurs that they get hit in the head and a concussion is possible, the ImPACT test will be administered the next school day to see if there are any deficits in addition to reporting symptoms of concussion. After the test is re-administered the student-athlete will take the results with them when they see a physician to assist in the official diagnosis by the physician.

 

 

***The full concussion policy is available for you to read if interested in the athletic training room. ***