Concussion Informed Consent Form

2023-2024 School Year


This consent form was developed to provide students, parents and legal guardians with current and relevant information regarding concussions and to comply with Connecticut General Statutes (C.G.S.) Chapter 163, Section 149b: Concussions: Training courses for coaches. Education plan. Informed consent form. Development or approval by State Board of Education. Revocation of coaching permit; and Section 10-149c: Student athletes and concussions. Removal from athletic activities. Notification of parent or legal guardian. Revocation of coaching permit.
What is a Concussion? 
National Athletic Trainers Association (NATA): A concussion is a "trauma induced alteration in mental status that may or may not involve loss of consciousness."
Centers for Disease Control and Prevention (CDC): "A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging the brain cells and creating chemical changes in the brain."
Section 1. Concussion Education Plan Summary 
The Concussion Education Plan and Guidelines for Connecticut Schools was approved by the Connecticut State Board of Education in January 2015. Below is an outline of the requirements of the Plan.
State law requires that each local and regional board of education must approve and then implement a concussion education plan by using written materials, on line training or videos, or in-person training that addresses, at a minimum, the following: 
  1. The recognition of signs or symptoms of a concussion.
  2. The means of obtaining proper medical treatment for a person suspected of sustaining a concussion.
  3. The nature and risks of concussions, including the danger of continuing to engage in athletic activity after sustaining a concussion.
  4. The proper procedures for allowing a student-athlete who has sustained a concussion to return to athletic activity.
  5. Current best practices in the prevention and treatment of a concussion.

Section 2. Signs and Symptoms of a Concussion: Overview 

A concussion should be suspected if any one or more of the following signs or symptoms are present, or if the coach/evaluator is unsure, following an impact or suspected impact as described in the CDC definition above.

Signs of a concussion may include (i.e. what the athlete displays/looks like to an observer): 

  • Confusion/disorientation/irritability
  • Trouble resting/getting comfortable
  • Lack of concentration
  • Slow response/drowsiness
  • Incoherent/slurred speech
  • Slow/clumsy movements
  • Loss of consciousness
  • Amnesia/memory problems
  • Acts silly, combative or aggressive
  • Repeatedly asks the same questions
  • Dazed appearance
  • Restless/irritable
  • Constant attempts to return to play
  • Constant motion
  • Disproportionate/inappropriate reactions
  • Balance problems

Symptoms of a concussion may include (i.e. what the athlete reports): 

  • Headache or dizziness
  • Nausea or vomiting
  • Blurred or double vision
  • Oversensitivity to sound/light/touch
  • Ringing in ears
  • Feeling foggy or groggy 

State law requires that a coach MUST immediately remove a student-athlete from participating in any intramural or interscholastic athletic activity who: a) is observed to exhibit signs, symptoms or behaviors consistent with a concussion following a suspected blow to the head or body, or b) is diagnosed with a concussion, regardless of when such concussion or head injury may have occurred. Upon removal of the athlete, a qualified school employee must notify the parent or legal guardian within 24 hours that the student athlete has exhibited signs and symptoms of a concussion. 

Section 3. Return to Play (RTP) Protocol Overview 
Currently, it is impossible to accurately predict how long an individual’s concussion will last.  There must be full recovery before a student-athlete is allowed to resume participating in athletic activity.  Connecticut law now requires that no athlete may resume participation until she/he has received written medical clearance from a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.

Concussion Management Requirements: 

  1. No athlete shall return to participation in the athletic activity on the same day of a concussion.
  2. If there is any loss of consciousness, vomiting or seizures, the athlete MUST be transported immediately to the hospital.
  3. Close observation of an athlete MUST continue following a concussion.  The athlete should be monitored following the injury to ensure that there is no worsening/escalation of symptoms.
  4. Any athlete with signs or symptoms related to a concussion MUST be evaluated by a licensed health care professional
  5. (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.
  6. The athlete MUST obtain an initial written clearance from one of the licensed health care professionals identified above directing her/him into a well-defined RTP stepped protocol similar to the one outlined below. If at any time signs or symptoms return during the RTP progression, the athlete should cease activity.
  7. After the RTP protocol has been successfully administered (no longer exhibits any signs or symptoms or behaviors consistent with concussions), final written medical clearance is required by one of the licensed health care professionals identified above for the athlete to fully return to unrestricted participation in practices and competitions.

Medical Clearance RTP protocol (at least one full day between steps recommended) 

Medical clearance chart

If at any time signs or symptoms should worsen during the RTP progression the athlete should stop activity that day. If the athlete’s symptoms are gone the next day, she/he may resume the RTP progression at the last step completed in which no symptoms were present. If symptoms return and do not resolve, the athlete should be referred back to her/his medical provider. 

I have read and understand the Student and Parent Concussion Informed Consent Form and the attached board of education policies regarding concussions and understand the severities associated with concussions and the need for immediate treatment of such injuries. 

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