NYOS Charter School

Concussion Acknowledgement Form

Please complete the form below. Mandatory fields marked *

Information

Definition of Concussion - means a complex pathophysiological process affecting the brain caused by a traumatic physical force or impact to the head or body, which may: (A) include temporary or prolonged altered brain function resulting in physical, cognitive, or emotional symptoms or altered sleep patterns; and (B) involve loss of consciousness.

Prevention

  • Teach and practice safe play & proper technique.
  • Follow the rules of play.
  • Make sure the required protective equipment is worn for all practices and games.
  • Protective equipment must fit properly and be inspected on a regular basis.

Signs and Symptoms of Concussion - he signs and symptoms of concussion may include but are not limited to: Head ache, appears to be dazed or stunned, tinnitus (ringing in the ears), fatigue, slurred speech, nausea or vomiting, dizziness, loss of balance, blurry vision, sensitive to light or noise, feel foggy or groggy, memory loss, or confusion.

Oversight - Each district shall appoint and approve a Concussion Oversight Team (COT). The COT shall include at least one physician and an athletic trainer if one is employed by the school district. Other members may include: Advanced Practice Nurse, neuropsychologist or a physician’s assistant. The COT is charged with developing the Return to Play protocol based on peer reviewed scientific evidence.

Treatment of Concussion - e student-athlete shall be removed from practice or competition immediately if suspected to have sustained a concussion. Every student-athlete suspected of sustaining a concussion shall be seen by a physician before they may return to athletic participation. The treatment for concussion is cognitive rest. Students should limit external stimulation such as watching television, playing video games, sending text messages, use of computer, and bright lights. When all signs and symptoms of concussion have cleared and the student has received written clearance from a physician, the student-athlete may begin their district’s Return to Play protocol as determined by the Concussion Oversight Team.

Return to Play - According to the Texas Education Code, Section 38.157:
A student removed from an interscholastic athletics practice or competition under Section 38.156 may not be permitted to practice or compete again following the force or impact believed to have caused the concussion until:

  • (1) the student has been evaluated, using established medical protocols based on peer-reviewed scientific evidence, by a treating physician chosen by the student or the student ’s parent or guardian or another person with legal authority to make medical decisions for the student;
  • (2) the student has successfully completed each requirement of the return-to-play protocol established under Section 38.153 necessary for the student to return to play;
  • (3) the treating physician has provided a written statement indicating that, in the physician ’s professional judgment, it is safe for the student to return to play; and
  • (4) the student and the student ’s parent or guardian or another person with legal authority to make medical decisions for the student:
  • (A) have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to return to play;
  • (B) have provided the treating physician ’s written statement under Subdivision (3) to the person responsible for compliance with the return-to-play protocol under Subsection (c) and the person who has supervisory responsibilities under Subsection (c); and
  • (C) have signed a consent form indicating that the person signing:
  • (i) has been informed concerning and consents to the student participating in returning to play in accordance with the return-to-play protocol;
  • (ii) understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return-to-play protocol;
  • (iii) consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191), of the treating physician ’s written statement under Subdivision (3) and, if any, the return-to-play recommendations of the treating physician; and
  • (iiii) understands the immunity provisions under Section 38.159.
  1. Date:*
  2. Student Signature Date:*