head injury reg guide acc

7/31/2019 Head Injury Reg Guide Acc

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Guiac r Implmigh Massachuss Rgulais

Ha Ijuris a Ccussisi Schl Ahlics

JANUARY 2012

HeAd StRonG


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Developed by the Massachsetts Department o Pblic Health

Janary 2012

Guiac r Implmigh Massachuss Rgulais

Ha Ijuris a Ccussisi Schl Ahlics

HeAd StRonG


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Section 11: Providing Inormation, Forms and Materials to Parents

and Athletes

11a) Annal Training Reqirement 47

11b) Notiying parents when an athlete has been 48

removed rom play or a sspected concssion

11c) Obtaining medical clearance or retrn to play 50

and academics ater a diagnosed concssion

11d) Completion o the Pre-participation Form 51

11e) Completion o Report o a Head Injry Form 52

Section 12: Inclsion o Sports-Related Head Injry Policy 54

in the Stdent and Parent Handbook

Section 13: Commnicating with Parents with Limited 57

English Prociency

Section 14: Otreach to Parents or Forms and Training Completion 59

Section 15: Sharing Concssion-Related Health Inormation 60

Section 16: Reqirements or Coaches, Athletic Trainers, Trainers

and Volnteers16a) Teaching Strategies that Minimize Sports-Related 62

Head Injry

16b) Prohibiting Dangeros Play 64

Section 17: Penalties 65

Additional Resources 66


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A srvey o middle and high school stdents has shown that 18% report

having symptoms associated with a concssion ater a blow to the head

dring etracrriclar athletics, annally.1 Given that there are approi-

mately 200,000 Massachsetts stdents involved in athletics (MIAA),

there are an estimated 36,000 stdent athletes a year eperiencing a pos-

sible concssion. A growing body o scientic literatre demonstrates theshort- and long-term risks o concssions. Retrning a stdent athlete to

play ater a known or sspected concssion places the stdent at risk or

long-term health conseqences, inclding serios injry or even death. The

risk o sbstantial injry is particlarly high i the athlete sers a sbse-

qent concssion beore completely recovering rom the prior one. This can

lead to prolonged recovery, or even to severe brain swelling (second impact

syndrome) with devastating and even atal conseqences.

In 2010, the Massachsetts Department o Pblic Health (MDPH) issed

the new reglation 105 CMR 201.000 Head Injuries and Concussions

in Extracurricular Athletic Activities, mandated by Chapter 166 of the

Acts of 2010, An Act Relative to Safety Regulations for School Athletes

(See theAdditional Resources section or a link to this statte). This

reglation reqires all pblic middle and high schools (serving grades

6 throgh high school gradation) and those non-pblic schools that

are members o the Massachsetts Interscholastic Athletic Association

(MIAA) to have policies and procedres governing the prevention and

management o sport-related head injries. The section in the reglations

on School Policies (105 CMR 201.006) states that these policies will

be developed by Janary 1, 20122 and will be reviewed and revised as

needed bt at least every two years. Frthermore, the reglation otlines

Frwr by hMassachuss dparm

Public Halh

1 Yoth Health Srvey, 2009, Massachsetts Department o Pblic Health.

2 In a Freqently Asked Qestions docment posted on the MDPH website, MDPH has

indicated that schools shold conrm that they have interim policies in place as o Janary

1, 2012 and then may nalize their policies by March 1, 2012 and conrm to the Depart-

ment that they have done so.

viiiFOREWORD BY THE MASSACHuSETTS DEPARTMENT OF PuBLIC HEALTH


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the 17 topic areas, at a minimm, that school policies shold address.

This docment is organized in 17 sections to provide gidance or each

o the areas identied in the reglations. Each section cites the relevant

sbsection o the reglation, provides clariying comments and incldes

sample policies. MDPH soght to bild in feibility wherever possible to

allow schools to incorporate the reqired head injry policies into eist-

ing policies and approaches to make implementation simpler. We haveattempted to highlight these areas o feibility throghot the docment

by inclding mltiple approaches that will satisy the reqirement.

These reglations and the reslting school policies are meant to prevent

concssions and minimize the health conseqences shold a concs-

sion occr. The reglations also emphasize a team approach, bringing

together all those in the school commnity responsible or stdent

athletes saety to nderstand the risks o concssions so they can re-

spond appropriately. Schools and school districts are encoraged to se

this docment and the model policies that have been shared by manyschools across the Commonwealth as a starting point as they develop

their own school policies that t local circmstances and refect the

districts niqe characteristics. Each school district or private school is

responsible or developing policies that are consistent with the regla-

tions and inclde all reqired inormation.

MPDH looks orward to working with schools, school districts and other

key partners to implement these reglations in order to promote the

health and saety o or stdent athletes.

ix HEAD STRONG: GuIDANCE FOR IMPLEMENTING THE MASSACHuSETTS REGuLATIONS ON HEAD INJuRIES AND CONCuSSIONS IN SCHOOL ATHLETICS


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Sampl 1:________ School/School District is committed to the saety o

all or stdent athletes. The prpose o this policy is to edcate

or coaches, parents, administrators, school personnel, voln-

teers and stdent athletes on the seriosness o brain injriesand concssions.3

A team o school sta consisting o or school nrse, athletic

department director, certied athletic trainer, coach, and school

administrator has developed these policies or ________ Pb-

lic Schools and they have been adopted by the ________

School Committee and Board o Trstees in consltation with the

________ Board o Health.

We have been inormed by the Massachsetts Department oPblic Health (MDPH) that while these policies are not sbject to

MDPH review, they mst be in accordance with MDPH reglations.

(SeeAdditional Resources at the back o this gide or a link to

these reglations.) ________ School will be sbmitting arma-

tions on or school letterhead to MDPH docmenting that we have

complied with the reglatory reqirement to develop appropriate

head injry policies. We will then pdate and sbmit this arma-

tion by September 30, 2013 and every two years thereater.

Sampl Irucis Schl Plics HaIjuris a Ccussis

i exracurricularAhlic Aciviis

3 Adapted rom Ldlow High School

10SAMPLE INTRODuCTIONS TO SCHOOL POLICIES ON HEAD INJuRIES AND CONCuSSIONS IN ExTRACuRRICuLAR ATHLETIC ACTIVITIES


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Sampl 2:4________ Pblic Schools seeks to prevent concssion and

provide a sae retrn to activity or all stdents ater an injry, par-

ticlarly ater a head injry. In order to eectively and consistently

manage these injries, the Athletic Department abides by the

ollowing procedres that have been developed to aid in ensringthat concssed athletes are identied, treated and reerred ap-

propriately, receive appropriate ollow-p medical care dring the

school day, inclding academic assistance, and are lly recovered

prior to retrning to athletic activity.

4 Adapted rom Lewis S. Mills High School, Connectict

11 HEAD STRONG: GuIDANCE FOR IMPLEMENTING THE MASSACHuSETTS REGuLATIONS ON HEAD INJuRIES AND CONCuSSIONS IN SCHOOL ATHLETICS


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Rgulai 105 CMR 201.006(A)(1):Designation, by the superintendent or head master,principal or school leader, o the person responsible

or the implementation o these policies and protocols,either the Athletic Director or other school personnel with

administrative authority.

Sci 1:

Prss Rspsibl rImplmai Schl

Plicy a Prcurs

ovrviw:The reglations speciy that each school or school district mst adopt

policies concerning the prevention and management o sports-related

head injries. The sperintendent mst designate the person respon-

sible or the development, implementation and revision o these policies.

This person may be the Athletic Director or other administrator. The

reglations speciy that these policies shold be developed by a team

consisting o: a school administrator, school nrse, school or team physi-

cian (i on sta), athletic director, certied athletic trainer (i on sta),

neropsychologist (i available), gidance conselor, and teacher in

consltation with any eisting school health/wellness advisory commit-

tee. The reglations rther speciy that the reglations shold be revised

by September 30, 2013 and every two years thereater.

5 Adapted rom Boston Pblic Schools

Prs Rspsibl Sampl Plicy 1:5The ________ Pblic School has designated its principal (and

his/her sta) who has administrative athority to oversee the

implementation o these policies and protocols governing the

prevention and management o sports-related head injries. In ad-

dition, the Principal will be responsible or:

(1) Spporting and enorcing the protocols, docmentation, train-

ing and reporting otlined in this policy;

12SECTION 1: PERSONS RESPONSIBLE FOR IMPLEMENTATION OF SCHOOL POLICY AND PROCEDuRES


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(2) Spervising and reviewing that all docmentation is in place;

(3) Reviewing, pdating and implementing policy every two years

and inclding pdates in annal training and stdent and parent

handbooks.

Prs Rspsibl Sampl Plicy 2:The ________ School District has designated its Athletic Director

to oversee the implementation o policies and protocols governing

the prevention and management o sports-related head injries. In

addition, the AD will be responsible or:

(1) Spporting and enorcing the protocols, docmentation, reqired

training and reporting;

(2) Assring that all docmentation is in place;

(3) Reviewing, pdating and implementing policy every two yearsand inclding pdates in annal training and stdent and parent

handbooks.



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traiig Rquirm Sampl Plicy 1:

6

It is etremely important to edcate or coaches, school person-nel, athletes and the commnity abot concssions. On a yearly

basis, all coaches, certied athletic trainers, trainers, and voln-

teers with the ________ Athletic Program mst complete the

online corse Concssion In Sports: What Yo Need to Know.

Rgulai 105 CMR 201.006(A)(2):Annual training o persons specied in 105 CMR 201.007in the prevention and recognition o sports-related head

injury, and associated health risks including second impactsyndrome, utilizing Department-approved training materialsor program, and documentation o each persons completion

o such training.

Sci 2:

Aual traiigRquirm

ovrviw:MDPH has specied that the ollowing persons mst receive MDPH-

approved annal training in sports-related concssion: coaches, certied

athletic trainers, trainers, volnteers, school and team physicians, school

nrses, athletic directors, marching band directors, parents o stdent

athletes and stdent athletes.

To comply with the reglations, this section o the schools policy mst:

inclde the annal training reqirement, conrm the se o MDPH-

approved materials, speciy how the training reqirement will be met and

how it will be docmented or each category o individal, and whether

any other categories o sta (sch as gidance conselors or teachers)

are also covered by the schools policy on the training reqirement.

There is, however, feibility in how these training reqirements may be

met, as shown by the three sample policies below.

A lik MdPH-apprvraiig ppruiisa raiig marials isavailabl i h AiialRsurcs sci.

6 Adapted rom Ldlow High School policy

14SECTION 2: ANNuAL TRAINING REQuIREMENT


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This corse is oered by the National Federation o State High

School Associations (NFHS). A certicate o completion mst be

sbmitted to the Athletic Director annally. Or stdent athletes

also need to know the importance o reporting a concssion to

their coaches, parents, athletic trainer and other school person-

nel. Every year, stdent athletes and their parents will participate

in an edcational training on concssions and sbmit a certicate

o completion to the Athletic Director prior to participating. One o

two trainings mst be completed:

CDC Heads-up Video Training or

An in-person training provided by ________ Pblic Schools and

approved by the Department o Pblic Health

These trainings will also be completed by school nrses and the

team physician and their certicates o completion provided to the

Athletic Director.

________ Pblic Schools also oers seminars, speakers, and

discssion panels on the topic o concssions. Seminars oer a

chance or the certied athletic trainer, athletic director and nrse

leader at the school to speak abot concssions and to discss

the protocol and policy that the School has enacted. Providing ed-

cation within the commnity will oer the residents and parents

o athletes in the City/Town o ________ the opportnity to ask

qestions and voice their concerns on the topic o brain injry and

concssions. When it comes to concssions, everyone shold be

aware o the potential dangers and remember that a concssionis a brain injry. Whenever anyone has a dobt abot a stdent

athlete with a brain injry, SIT THEM OUT and have them see the

appropriate healthcare proessional!

traiig Rquirm Sampl Plicy 2:The Commonwealth o Massachsetts reqires annal saety train-

ing on prevention, identication and management o a sports-related

injry inclding head trama and second impact syndrome or

designated school personnel as well as parents or legal gardians

o children who participate in any etracrriclar athletic activity.

This annal saety training shall be reqired or ________ Schools

coaches, certied athletic trainers, trainers, volnteers, school nrses,

school and team physicians, athletic directors, directors responsible

or a school marching band whether employed by a school or school



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7 Adapted rom Marsheld Pblic Schools

8 In accord with 105 CMR 201.016

district or serving as a volnteer, parent or legal gardian o a child

who participates in an etracrriclar athletic activity and stdent

who participates in an etracrriclar athletic activity.7

This training eort shall be in collaboration with ________

Schools Principal and central oce administration team and

docmentation o sch training will be provided to the Principal or

maintenance in a central le.

While not reqired by MDPH, ________ School also oers this

training to gidance conselors, physical edcation teachers, and

other school personnel. In addition, or schools Game ocials

shall complete one o the training programs approved by the De-

partment o Pblic Health.

The trainings available or ________ School or school sta, par-

ents/gardians and stdent athletes are MDPH Approved Online

Training corses listed below. They are available ree o charge and

last only abot 30 mintes.

Centers or Disease Control and Prevention Heads up Concs-

sion in Yoth Sports On-Line Training Program (www.cdc.gov/

concssion/Headsup/online_training.html)

National Federation o State High School Associations Concs-

sion in Sports What Yo Need to Know (www.nhslearn.com/

electiveDetail.asp?corseID=15000)

The training materials are available at ________ Schools athleticdepartment website (..ed), and hard copies are avail-

able in the athletic department oce, the school nrse oce and

the athletic handbook.

________ Schools athletic director is responsible or ensring

that the training reqirements or sta, parents, volnteers, coach-

es and stdents are met, recorded, and records are maintained.8

The written verication o completion o the annal training (either

the certicate o completion rom the on-line corses or a signedverication that written materials have been read and nderstood)

will be kept on le by the ollowing Department Heads:

Nrse Leader: all school nrses and the School Physician

Consltant

16SECTION 2: ANNuAL TRAINING REQuIREMENT
http://www.cdc.gov/concussion/HeadsUp/online_training.htmlhttp://www.cdc.gov/concussion/HeadsUp/online_training.htmlhttp://www.nfhslearn.com/electiveDetail.aspx?courseID=15000http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000http://www.cdc.gov/concussion/HeadsUp/online_training.htmlhttp://www.cdc.gov/concussion/HeadsUp/online_training.html


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Physical examiai Sampl Plicy 1:9Every stdent in ________ School mst be separately and care-

lly eamined by a dly licensed physician, nrse practitioner or

physician assistant, prior to a stdents participation in competitive

athletics, on an annal basis. The completed and signed copy o the

medical clearance orm shold be mailed, aed or hand-deliveredto either the school nrse or athletic oce. No stdent athlete will

be allowed to participate in athletic activities ntil all orms, incld-

ing annal physical eaminations, are signed and sbmitted.

Rgulai 105 CMR 201.006(A)(3):Documentation o physical examination prior to a students

participation in extracurricular athletic activities on anannual basis, consistent with 105 CMR 200.100(B)(3) andinormation or students participating in multiple sports

seasons that documentation o one physical examinationeach year is sucient.

Sci 3:

dcumai Physical exam

ovrviw:Stdents mst have an annal physical eamination to assre that

they are sciently healthy or athletic activity. Ideally, the physical

eamination shold be done by the primary care provider in the st-

dents medical home. To comply with the reglations, this policy section

mst inclde the reqirement o an eam on an annal basis and the

schools interpretation o how oten sch eams will be reqired, where

physical eamination orms will be kept, who will be responsible or

assring that stdents are notied when physical eams epire, and con-

seqences o athletes not meeting annal physical eam reqirements.

9 Adapted rom Massachsetts Department o Pblic Health Comprehensive School Health

Manal, 2007, Weston Pblic Schools and 105 CMR 200.100 Physical Eamination o

School Children

18SECTION 3: DOCuMENTATION OF PHYSICAL ExAM


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Frequency o Exam: As a matter o school policy, ________

School accepts physical eaminations completed within 13

months to allow or insrance coverage that wold be not be pos-

sible i eaminations are within a 12 month period. This medical

eamination shold be completed by a physician, nrse practitio-

ner, etc. and shold athorize the stdent athlete who participates

in mltiple sports seasons dring the ollowing 13 months that the

stdent is medically cleared to do so.

Where Forms Are Kept: The crrent annal medical eamination

orm shold be sbmitted to the school nrse. It shold also be

kept in the stdents medical record. The school nrse and/or

athletic director shold ensre that all stdent athletes that are

participating in etracrriclar school sports have been medically

cleared annally.

A stdent athlete at ________ School cannot participate in an

etracrriclar sports activity i she/he has not had a physical

eamination within the last 13 months.

Physical examiai Sampl Plicy 2:Each stdent athlete mst have a physical eamination on an

annal basis, i.e. within 12 or 13 months o the stdents last

physical eamination (to allow or insrance coverage o the eam-ination). Any stdent athlete who does not have a crrent physical

on le with the nrse, prior to the rst day o tr y-ots/practice,

is not eligible ntil a new/pdated physical is trned in. I the

stdents physical eamination epires dring the sports season,

he/she mst have an pdated physical eamination to contine

to participate in the sports season. All physicals are to be trned

in to the nrse, not the coach. A new sports physical orm mst

be lled ot every all or prior to participating in the stdents rst

sport o the season and sbmitted to the school nrse even i the

inormation has not changed.



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Rgulai 105 CMR 201.006(A)(4):Procedure or the school to obtain and ensure review, prior

to each sports season, o current inormation regardingan athletes history o head injuries and concussion usingeither the Department Pre-participation Health Injury/

Concussion Reporting Form For Extracurricular Activities, orschool-based equivalent.

Sci 4:

Pr-Paricipai HaIjury Rprig Frms,

Submissi a Rviw

ovrviw:Both the law and reglations reqire stdent athletes and their parents

to provide an accrate history o head injry to the school prior to each

athletic season. The Department has developed a pre-participation

reporting orm that may be ond in theAdditional Resources section,

as well as on the Departments website. Schools may tilize this orm or

a school-based eqivalent orm which contains all o the same inor-

mation as the Departments orm, bt cold be part o another orm or

contain additional inormation the school wishes to collect. The ollowing

elements shold be inclded in the school-based eqivalent o the Pre-

participation orm:

Instrctions stating this orm shold be completed by stdents parent(s)

or legal gardian and sbmitted to the Athletic Director or ocial desig-

nated by the school, prior to the start o each season a stdent plans to

participate in an etracrriclar athletic activity.

Stdents Name, Se, Date o Birth, Grade

School Name and Sport(s)

Home Address and Telephone #

Has stdent ever eperienced a tramatic head injry (a blow to the

head)? (I yes, when?)

Has stdent ever received medical attention or a head injry? (I yes,

when?)

Was stdent diagnosed with a concssion? (I yes, when?)

Drations o symptoms or most recent concssion

Parent or gardians printed name, signatre and date

Stdent athletes printed name, signatre and date

20SECTION 4: PRE-PARTICIPATION HEAD INJuRY REPORTING FORMS, SuBMISSION AND REVIEW


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10 Adapted rom Marsheld Pblic Schools, MDPH Sports-related Head Injry Reglations

FAQs, and 105 CMR 201.008(A)

To comply with the reglations, this section o the schools policy mst

inclde: the method or collection o pre-participation orms, who will

receive the orms and the conseqences or ailre to provide the orms

prior to the start o the sports season.

Ccussi Hisry Frm Submissi a RviwSampl Plicy:10

The Massachsetts concssion law reqires athletes and their

parents to inorm coaches abot prior head injries at the be-

ginning o each sports season. This reporting is done via the

Pre-participation Head Injury/Concussion Reporting Form

and shold be completed by the stdents parent(s) or le-

gal gardian(s) and the stdent. It mst be sbmitted to the

________ Schools Athletic Director,priorto the start o each

season a student plans to participate in an extracurricular

athletic activity. This orm provides a comprehensive history with

p-to-date inormation relative to concssion history. This orm is

designed to ensre that particlar attention is paid to identiying

athletes with a history o brain or spinal injries. For eample, it

asks sch qestions as:

Has stdent ever eperienced a tramatic head injry (a blow to

the head)? (I yes, when?)

Has stdent ever received medical attention or a head injry?

(I yes, when?)

Was stdent diagnosed with a concssion? (I yes, when?)

Drations o symptoms or most recent concssion.

Until the pre-participation orm (or school-based equivalent)

is completed and signed by the parent/guardian and student

and returned to the school prior to the start o every sports

season, the student cannot participate in the extracurricular

sports activity.

History o Multiple Concussions on Pre-participation Form: The

decision to allow a player who reported a history o mltiple con-

cssions on her/his pre-participation orm shold be made only

ater consltation with the stdents physician or primary care pro-

vider; the sports medicine or concssion specialist, i involved; theneropsychologist, i involved, and the appropriate school athletic

sta and the parent. Crrent evidence indicates that yoth who

have sered one or more concssions are more likely to ser a



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sbseqent one. Options may inclde switching positions, limiting

contact in practices, or changing sports altogether to minimize the

risk o re-injry. The ocs o ________ School will always be on

protecting the health and saety o the stdent and avoiding long-

term conseqences that can occr rom repeated concssions.

Collection/Distribution o Pre-participation Forms: ________

School has the pre-participation orms available electronically at

the Schools website nder the Athletic Department older at .

.ed. Hard copies o these orms are also available at the

Athletic Department and School Nrsing oce.

The parent/stdent can a, mail, or hand-deliver the completed

and signed pre-participation orm to the ________ Schools

athletic department which will orward a copy to the school nrse.

In addition, dring the months o Jly and Agst, coordination be-

tween the athletic and school nrsing departments is particlarly

important when the school nrse is on vacation. The pre-par-

ticipation orms shold be sbmitted to the coaches or athletic

directors who will then ollow-p with the school nrse when s/he

retrns to work in September.

S h Aiial Rsurcssci r a lik MdPHPr-paricipai Ha Ijury/Ccussi Rprig Frm rexracurricular Aciviis ahr Schl-bas quivals.

22SECTION 4: PRE-PARTICIPATION HEAD INJuRY REPORTING FORMS, SuBMISSION AND REVIEW


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Rgulai 105 CMR 201.006(A)(5):Procedure or medical or nursing review o all Pre-

participation Forms indicating a history o head injury.

Sci 5:

Mical/nursig Rviw Pr-Paricipai Frms

ovrviw:In order to assre that stdents who have eperienced a concssion/

head injry in the past are sae to play, the school mst ensre timely

review by either the school nrse or the school physician o all pre-partic-ipation orms that indicate a history o head injry.

To comply with the reglations, this section o the policy mst speciy

how this review will take place as well as how a stdents history o

head injry/concssion may actor into the decision o whether to allow

contined participation in athletics or whether to modiy the specic

conditions o sch participation.

Mical Rviw Pr-Paricipai FrmSampl Plicy:11

At the start o each sports season, the Athletic Director will review

all pre-participation orms and orward to the school nrse those

orms indicating a history o head injry. The school nrse will be

responsible or:

Reviewing or having the school physician review completed pre-

participation orms

Addressing any qestions raised by the Athletic Director

Commnicating with the coach regarding the stdents concs-

sion history and discssing concernsFollowing p with parents and stdents as needed prior to the

stdents participation in etracrriclar athletic activities.

11 Ecerpted rom Boston Pblic Schools and 105 CMR 201.015



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Rgulai 105 CMR 201.006(A)(6):Procedure or the school to obtain and ensure timelymedical or nursing review o a Department Report o a

Head Injury During Sports Season Form, or school-basedequivalent, in the event o a head injury or suspectedconcussion that takes place during the extracurricular

activity season.

Sci 6:

Mical/nursig Rviw Rprs Ha Ijury

durig h Sas

ovrviw:As with Section 5, in order to assre that stdents who eperience

concssion/head injry are sae to play, the school mst ensre timely

review o all report o head injry orms by either the school nrse or

the school physician. The Department has developed a Report o Head

injury During the Sports Season Form. A link to this orm may be ond

in theAdditional Resources section as well as on the Departments

website. Schools may tilize this orm or a school-based eqivalent

orm which mst contain all o the same inormation as the Departments

orm, bt cold be part o another orm or contain additional inormation

the school wishes to collect. The ollowing elements shold be inclded

in the school-based eqivalent o the Report o Head Injury Form:

Instrctions to Coaches to ll ot the orm immediately ater the game

or practice or head injries that reslt in stdent being removed rom

play de to a possible concssion. Coaches shold also ollow-p with

the Certied Athletic Trainer as well as parent/gardian the same day/

night o the injry.

Instrctions to Parents/Gardians to ll ot the orm i the injry oc-

crs otside o an athletic practice or game and retrn to school nrse.

Stdents Name, Se, Date o Birth, Grade

School Name and Sport(s)

Home Address and Telephone #

Date o Injry

Did the incident take place dring an etracrriclar activity? I so,

where did the incident take place?

Describe the natre and etent o injries to the stdent.

24SECTION 6: MEDICAL/NuRSING REVIEW OF REPORTS OF HEAD INJuRY DuRING THE SEASON


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Mical/nursig Rviw Sampl Plicy 2:13

The ollowing procedres will be ollowed when an athlete receives

a head injry:

Athlete is removed rom the contest or practice.

The certied athletic trainer condcts a Standardized Assess-

ment of Concussion and completes the Report o Head InjuryDuring Sports Season Form.

I certied athletic trainer is not available, coach completes the

Report o Head Injury During Sports Season Form

The certied athletic trainer/coach will give Report o Head

Injury During Sports Season Form to Director o Athletics.

Director o Athletics will notiy school nrse and/or school physi-

cian (i appropriate) who will review the Report o Head Injry orm.

School nrse will contact athletes teachers and gidance conselor.

13 Adapted rom Northampton High School

S h Aiial Rsurcssci r a lik h MdPHRpr Ha Ijury durigSprs Sas rm a schl-bas quival rms.

26SECTION 6: MEDICAL/NuRSING REVIEW OF REPORTS OF HEAD INJuRY DuRING THE SEASON


26/68

Rgulai 105 CMR 201.006(A)(7):Procedure or reporting head injuries or suspected concussions

sustained during extracurricular athletic activities to theschool nurse and certied athletic trainer, i on sta.

Sci 7:

Prcur r RprigHa Ijuris

Schl nurs a/rCrif Ahlic trair

ovrviw:Becase medical evalation and ongoing monitoring o a stdents recov-

ery rom concssion is so important or a stdents saety, schools shold

have in place a procedre or assring that head injries or concssion

sstained dring play or practice are reported to the school nrse and

certied athletic trainer.

To comply with the reglations, this section o the school policy mst

inclde: specics regarding how the school nrse and certied athletic

trainer will be notied, what inormation abot the head injry will be

shared, and their role in evalation and monitoring o the head injry.

Many schools have combined policies reqired by Sections 6 and 7 and

there is feibility in how these reqirements may be met as demonstrat-

ed by the mltiple sample policies below.

Rprig Ha Ijury Sampl Plicy 1:14

At ________ School head injries or sspected concssions

(ater a bmp, blow or jolt to the head or body) sstained dringetracrriclar athletic activities mst be reported by the coach

as soon as possible to the school nrse and the certied athletic

trainer.Athletes who experience signs or symptoms o a concus-

sion should not be allowed to return to play.

14 Adapted rom Marsheld Pblic Schools and 105 CMR 201.010(A)



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Rprig Ha Ijury Sampl Plicy 2:15Coaches will report all head injries to the Certied Athletic Trainer

as soon as possible or medical assessment and management

and coordination o home instrctions and ollow-p care. The

Certied Athletic Trainer can be reached at --. The athletic

trainer will notiy the school nrse o the stdents injry, prior tothe net school day, so that the school nrse can initiate appropri-

ate ollow-p in school immediately pon the athletes retrn to

school. (Note that the coach will be responsible or commnicat-

ing the stdents injry with parents/gardians.)

Rprig Ha Ijury Sampl Plicy 3:16When a stdent athlete obtains a head injry dring an etracr-

riclar athletic activity, the ollowing steps mst be ollowed:Physician or certied athletic trainer evalates the stdent.

Coach completes Report o Head Injury Form and sends copy

to school nrse.

School nrse noties athletic director, gidance, and stdents

teachers o injry and any modications ordered by MD.

Coaches assre that stdent athlete adheres to the protocol.

Physician noties school nrse o stdents progression.

School nrse noties all necessary sta o progression, recovery

and retrn-to-play.

15 Adapted rom Params Pblic Schools

16 Adapted rom Ashbrnham Westminster Regional School District

28SECTION 7: PROCEDuRE FOR REPORTING HEAD INJuRIES TO SCHOOL NuRSE AND/OR CERTIFIED ATHLETIC TRAINER


28/68

Rgulai 105 CMR 201.006(A)(8):Procedure or identiying a head injury or suspected

concussion, removing an athlete rom practice orcompetition and reerring or medical evaluation.

Sci 8:

Rmvig Ahlsrm Play a

Mical evaluai

ovrviw:Becase contining athletic activity ater sstaining a concssion can bedangeros, and can reslt in both short- and long-term conseqences p

to and inclding death, removing an athlete rom play who has sstained

a head injry or sspected concssion is crcial. Diagnosing a concs-

sion on the sidelines is not sae or acceptable practice, nor is retrning

an athlete to play a ew mintes ater a blow to the head i symptoms

appear to resolve. Research has demonstrated that what have previ-

osly been considered dings or bell ringers can be serios events. The

law and the reglations reqire that players who have symptoms consis-

tent with a sspected concssion mst be removed rom play, and may

not retrn to play or practice that same day.

Althogh the reglations specically assign responsibility to coaches and

certied athletic trainers to remove athletes rom play or head injries

or sspected concssions, the Department o Pblic Health epects that

there will be a shared nderstanding o the symptoms and risks o con-

cssion among athletes and other adlts who are present dring practice

or competition. I there is any disagreement among responsible person-

nel regarding whether the stdent has sstained a head injry or has

symptoms sggestive o a concssion, the stdent shold be removed

rom play, as that is the saest option or the stdent. Following a concs-

sion, commnication between amilies, edcational personnel, athletic

sta and health care providers is crcial to acilitate a stdents healthy

retrn to school and physical activity ollowing a concssion.17




29/68

18 Adapted rom Params High School Policy

To comply with the reglations, this section o a schools policies mst

inclde: clarity regarding removal rom play or any athlete with a head injry

or sspected concssion, a statement that head injred athletes will not be

retrned to play/practice that day (even i symptoms appear to resolve),

any procedres or docmenting signs and symptoms o concssion,

procedre or notiying school medical personnel and initiating emergency

medical services when needed, and procedre or notication o parents.

Dierent schools/school districts have developed compliant policies

and protocols appropriate to their needs and resorces. Samples are

inclded below.

n: th Aiial Rsurcssci cais a lik a Fac Sh Sigs aSympms Ccussi.

Iiyig Ha Ijury r Suspc Ha Ijurya Rmvig rm Play Sampl Plicy 1:18

In the event that a stdent athlete receives a head injry, or issspected o having a head injry, the stdent will be removed

rom play and will not be retrned to play or practice that day.

The coach shold report the head injry to the certied athletic

trainer or school nrse/physician as soon as possible, or medi-

cal assessment and management and or coordination o home

instrctions and ollow-p care. The certied athletic trainer or

school nrse/physician will be responsible or contacting the ath-

letes parents and providing ollow-p instrctions. I the athlete

is injred at an away event or i the certied athletic trainer is

navailable, the coaching sta are responsible or notiying theathletes parents o the injry and, i warranted, calling or emer-

gency care. Coaches shold seek assistance rom the host site

athletic trainer, coach or school nrse i at an away event.

I the athlete is able to be sent home (rather than directly to MD): a)

the coach or athletic trainer will ensre that the athlete will be with a

responsible adlt, who is capable o monitoring the athlete and n-

derstanding the home care instrctions, beore allowing the athlete

to go home; b) the coach or athletic trainer will contine eorts to

reach the parents; c) i there is any qestion abot the stats o theathlete, or i the athlete is not able to be monitored appropriately,

the athlete will be reerred to the emergency department or eval-

ation. A coach or athletic trainer will accompany the athlete and

remain with the athlete ntil the parents arrive and d) athletes with

sspected head injries will not be permitted to drive home.

30SECTION 8: REMOVING ATHLETES FROM PLAY AND MEDICAL EVALuATION


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19 Adapted rom Marsheld Pblic Schools and the Deter and Sotheld Schools


Iiyig Ha Ijury r Suspc Ha Ijurya Rmvig rm Play Sampl Plicy 2:19I a stdent athlete receives a blow to the head and anysigns or

symptoms are present or i the stdent is sspected o having a

head injry the coach or athletic trainer mst remove the stdent

rom play/practice and the stdent will not retrn to play/practice thatday. The stdent will be reerred to the school nrse who shold: a)

Reer stdent immediately to their primary care physician or i navail-

able, emergency room, b) Send copy o the symptom checklist with

the stdent or review by medical personnel. The coach will also be

responsible or notication o parents/legal gardians.

Iiyig Ha Ijury r Suspc Ha Ijury

a Rmvig rm Play Sampl Plicy 3:20In the event that a stdent athlete receives a head injry, the

certied athletic trainer will se the Standardized Assessment or

Concssion (SAC) Form A (Standardized Assessment o Concs-

sion) to assess and docment the stdent athletes concssion.

The athletic trainer will also report on the stdent athletes signs

and symptoms o a concssion by sing the Signs and Symptoms

Check-List. The athletic trainer will also check plse and blood

pressre o each stdent athlete with a sspected concssion.

Ater the initial evalation o a concssion, all signs and symptoms

will be tracked on the compter sing the ImPACT Test.

Any athlete who is symptomatic bt stable is allowed to go home

with their parent(s) or legal gardian(s) ollowing the head injry.

I the head injry occrs at practice, a parent(s) or legal gardian(s)

will immediately be notied and mst come and pick-p the st-

dent athlete and talk to the certied athletic trainer in person.

I the injry occrs at a game or event they may go home with

their parent(s) or legal gardian(s) ater talking with the certied

athletic trainer.

Parent(s) or legal gardian(s) will receive important inormation

regarding signs and symptoms o deteriorating brain injry/

nction prompting immediate reerral to a local emergency room

as well as retrn to play reqirements at the school. Parent(s) or

legal gardian(s) as well as stdent athletes mst read and sign



31/68

the Concssion Inormation and Gradal Retrn to Play orm and

bring it back to the certied athletic trainer beore starting with the

retrn to play protocol. All symptomatic stdents will be reerred to

their primary care provider or evalation.

When an athlete loses consciosness or any reason, the athletic

trainer will start the Emergency Action Plan by activating EMS,

recognize ABCs, stabilize the C-spine and transport the injred

athlete to the local hospital via amblance. I the athletic trainer is

not present, the coach shold call EMS immediately, check ABCs

and not move athlete ntil help arrives.

Any athlete who is removed rom the competition or event and

begins to develop signs and symptoms o a worsening brain injry

will be transported to the hospital immediately in accordance

with the Emergency Action Plan.Worsening signs and symptoms

requiring immediate physician reerral:21

Amnesia lasting longer than 15 mintes

Deterioration in nerological nction

Decreasing level o consciosness

Decrease or irreglarity in respirations

Decrease or irreglarity in plse

Increase in blood pressre

uneqal, dilated, or n-reactive ppils

Cranial nerve decits

Any signs or symptoms o associated injries, spine or skll

ractre, or bleedingMental-stats changes: lethargy, diclty maintaining arosal,

consion, agitation

Seizre activity

Vomiting/worsening headache

Motor decits sbseqent to initial on-eld assessment

Sensory decits sbseqent to initial on-eld assessment

Balance decits sbseqent to initial on-eld assessment

Cranial nerve decits sbseqent to initial on-eld assessment

Post-Concssion symptoms worsen

Athlete is still symptomatic at the end o the game

21 From Ldlow High Schools policies, this ootnote rom Prentice, Willilam E., Arnheims

Principles o Athletic Training: A Competency-Based Approach. 12th ed. New York: McGraw

Hill. 2006. p. 872-890.

32SECTION 8: REMOVING ATHLETES FROM PLAY AND MEDICAL EVALuATION


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Rgulai 105 CMR 201.006(A)(9):The protocol or medical clearance or return to play

ater a concussion that at a minimum complies with 105CMR.201.011.

105 CMR 201.011:Each student who is removed rom practice or competition ora head injury or suspected concussion, or loses consciousness,even briefy, or exhibits signs and symptoms o a concussion,

shall obtain and present to the Athletic Director, unlessanother person is specied in school policy or procedure,a Department Post Sports-Related Head Injury Medical

Clearance and Authorization Form (Medical Clearance andAuthorization Form), or school-based equivalent, prior to

resuming the extracurricular athletic activity. This ormmust be completed by a physician or one o the individualsas authorized by 105 CMR 201.011(A). The ultimate return

to play decision is a medical decision that may involve amultidisciplinary approach, including consultation withparents, the school nurse and teachers as appropriate.

105 CMR 201.011(A):Only the ollowing individuals may authorize a studentto return to play:(1) A duly licensed physician;(2) A duly licensed certied athletic trainer in

consultation with a licensed physician;(3) A duly licensed nurse practitioner in consultation

with a licensed physician; or(4) A duly licensed neuropsychologist in coordination

with the physician managing the students recovery.

Sci 9:

Mical Clarac rRur Play

ovrviw:I an athlete is removed rom play or a sspected concssion, he or

she mst be medically cleared and evalated beore retrning to play/

practice. I the stdent was diagnosed with a concssion, the medical

clearance can only be provided aterhe or she has completed a grad-

ated retrn to play plan indicating they are ready to resme physical



33/68

Rur Play Sampl Plicy 1:The ________ school physician, i available, shold also be

involved. Medical clearance is meant to be provided AFTER a

student has completed his or her graduated return to play plan.

The medical provider giving medical clearance or retrning to

play mst se the MDPH Medical Clearance Form, Post Sports-

Related Head Injury Medical Clearance and Authorization

Form, available on the MDPH website (www.mass.gov/eohhs/

docs/dph/com-health/injry/posthead-injry-clearance-orm.

pd), or a school-based eqivalent that incldes the same

activity. To provide this clearance, MDPH has developed a Sports Re-

lated Head Injury Medical Clearance and Authorization Form whose

link may be ond in theAdditional Resources section or on the MDPH

website. Schools may se this orm or a school-based eqivalent incld-

ing the same inormation. The orm may inclde additional inormation

the school wishes to collect. The ollowing elements shold be inclded

on the school-based eqivalent:Stdents name, se, date o birth, grade

Date o Injry

Symptoms and their dration

Diagnosis

I a concssion was diagnosed, date o completion o gradated RTP plan

Past history o previos concssions

Health providers name, address, phone #

Health providers designation as physician, CAT, NP or neropsychologist

I not physician, name o physician providing consltation or coordination

Signatre and date o health provider providing clearance

In order to comply with the reglations, this section o the schools policies

mst inclde: conrmation that stdents may not retrn to play/practice

ntil medical clearance is obtained, what orm will be sed, who reviews

the medical clearance, where orms will be kept, and what procedres

will be ollowed i symptoms are observed ater a stdent resmes physi-

cal activity. For more inormation abot gradated retrn to play plans,

see Section 10 o this docment. O note, the athlete mst be completely

symptom-ree at rest beore beginning a gradated retrn to play process.

There is sbstantial feibility to develop policies and protocols that meet

the needs and resorces o a particlar school or school district. This is

refected in the sample policies below.

34SECTION 9: MEDICAL CLEARANCE FOR RETuRN TO PLAY
http://www.mass.gov/eohhs/docs/dph/com-health/injury/posthead-injury-clearance-form.pdfhttp://www.mass.gov/eohhs/docs/dph/com-health/injury/posthead-injury-clearance-form.pdfhttp://www.mass.gov/eohhs/docs/dph/com-health/injury/posthead-injury-clearance-form.pdfhttp://www.mass.gov/eohhs/docs/dph/com-health/injury/posthead-injury-clearance-form.pdfhttp://www.mass.gov/eohhs/docs/dph/com-health/injury/posthead-injury-clearance-form.pdfhttp://www.mass.gov/eohhs/docs/dph/com-health/injury/posthead-injury-clearance-form.pdf


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22 Adapted rom a nmber o sorces, inclding Marsheld High School

inormation. The Medical Clearance Form contains more detailed

inormation than a simple statement that the stdent is ready

to retrn to athletics. This additional inormation is necessary as

school sta monitors the stdent retrning rom a concssion.

Athletic sta may consider providing this orm to the athlete to

share with the physician. The completed orms shold be kept in

the stdents medical record in the school health oce as well as

athletic department oce.

Rur Play Sampl Plicy 2:22

All stdents at ________ School mst be cleared to retrn to

play/practice by a licensed medical proessional (physician, NP in

consltation with a physician, CAT in consltation with a physician

or neropsychologist in coordination with the physician manag-ing the stdents recovery) after the graduated return to play has

been completed. (See details abot gradated retrn to play

practices below nder Section 10). It is recommended that this

medical proessional have amiliarity with concssion diagnosis

and management in order to determine how serios the concs-

sion is and when it is sae or the stdent to retrn to normal

activities inclding physical activity and school (concentration and

learning activities). Sports activities inclde physical edcation

class as well as sports practices and games:

The stdent shold be completely symptom ree at rest and with

physical (sprints, non-contact aerobic activity) and cognitive

eertion (school work).

Retrn to play shold occr gradally (see below).

Stdents shold be monitored or symptoms and cognitive nc-

tion dring each stage o eertion.

Stdents shold only progress to the net level o eertion i they

are asymptomatic at the crrent level.

Medical clearance will be provided sing the orm whose link can

be ond in theAdditional Resources section o these poli-

cies and also available on the ________ School website. It is

recommended that the stdent take this orm to the medical pro-

essional at the time o eam as other orms will not be accepted.

These orms mst be provided to the coach or athletic trainer and



35/68


Rur Play Sampl Plicy 3 (Wh schlsus ImPACt r hr sig rquir byrgulais):23

Following a diagnosed concssion made by a healthcare provider,

the stdent athlete will take a post-injry test within 24 to 48

hors ollowing the head injry. STuDENT ATHLETES WILL NOT BE

ALLOWED TO MOVE ONTO FuNCTIONAL/PHYSICAL TESTING uNTIL

THEIR IMPACT TEST IS BACK TO THE BASELINE SCORE AND THEY

ARE ASYMPTOMATIC. Ater a stdent athlete takes their rst post-

injry test, they will not be re-tested again or 5 days.

I ater the rst post-injry ImPACT test the athlete is not back to

his/her baseline, the parent(s) or legal gardian(s) will be notied,

and the stdent athlete will be reerred back to their healthcare

provider and mst have the Concssion Inormation and Gradal

Retrn to Play orm signed by a physician, licensed neropsychol-

ogist, nrse practitioner or certied athletic trainer stating when

the athlete is allowed to retrn play.

Following a post-injry test, the certied athletic trainer will take

the Concssion Inormation and Gradal Retrn to Play orm

signed by the parent(s) or legal gardian(s) and ll in the date o

all post-injry tests taken by each stdent athlete.

will be shared with the school nrse or review with a copy kept in

the stdents medical record.

In a sitation in which a stdent has been medically cleared bt

school sta have observed contining symptoms, the school will

make the nal decision regarding a stdents to retrn to play.

I this sitation arises, the ________ School sta shold com-

mnicate to the physician or health care provider who provided

the clearance regarding the symptoms which school sta have

observed, to allow or reevalation by the health care provider.

It is possible that the health care provider was not aware o the

stdents symptoms when the provider gave the clearance. I the

athlete still has symptoms, the athlete shold NOT retrn to play.



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The certied athletic trainer will also docment the date on which

the athlete is asymptomatic and sign the docment agreeing that

all the above statements are tre and accrate.

Once the athlete completes the eertional post concssions tests,

the parent(s) or legal gardian will be notied and the athlete will

be sent home with all signed docments relating to head injry.

At this time the parent(s) or legal gardian mst bring the stdent

athlete to a licensed physician, licensed neropsychologist, nrse

practitioner, or certied athletic trainer to be medically cleared or

participation in etracrriclar athletic activities.

Once a stdent athletes post-injry test is back at the stdent

athletes baseline score they will go throgh 5 days o Eertional

Post Concssion Tests. The stdent athlete mst be asymptomatic

or all nctional and physical tests to retrn to play (RTP). All tests

will be administered by a certied athletic trainer.

Rur Play Sampl Plicy 4:24

I it is determined that an athlete has a concssion or sspected

concssion, he/she will be ot o competition ntil he/she can

be cleared or participation by a physician. No player shall go

rom being sidelined with a concssion to ll play ntil he/shehas ollowed the recommended stepwise process rom the treat-

ing physician regarding retrn to activity. Each athlete will likely

have his/her own corse o recovery, which may depend pon

prior medical history o concssion. Each stdent who is removed

rom practice or competition shall have a written gradated re-

entry plan or retrn to ll academic and etracrriclar athletic

activities. The plan shall be developed by the stdents teachers,

the stdents gidance conselor, school nrse, certied athletic

trainer i on sta, neropsychologist i available or involved, parent,

members o the bilding-based stdent spport and assistance

team or individalized edcation program team as appropriate

and in consltation with the stdents primary care provider or

the treating physician. This written plan shall inclde instrctions

or stdents, parent(s) and school personnel addressing physical

and cognitive rest, gradated retrn to academics and athletics,

24 Adapted rom the Deter and Sotheld Schools



37/68

estimated time intervals or resming activities, assessment

reqencies, as appropriate, by the school nrse, physician, team

physician, athletic trainer i on sta, or neropsychologist i avail-

able ntil ll retrn to academics and athletics is athorized. A

plan or commnication and coordination shall also be pt into

place with the above individals who are managing the stdents

recovery. The stdent mst be completely symptom-ree at rest in

order to begin gradated re-entry (stepwise program) to activities.

Final athority or retrn to play shall reside with the stdents

physician or the physicians designee.



38/68

Sci 10:

dvlpm aImplmai

Ps CcussiGraua Rry Plas

Rgulai 105 CMR 201.006(A)(10):Procedure or the development and implementation opost-concussion graduated reentry plans to school andacademic activities, i indicated, by persons specied in

CMR 201.010(E)(1).

105 CMR 201.010(e):Each student who is removed rom practice or competitionand subsequently diagnosed with a concussion shall have awritten graduated reentry plan or return to ull academicand extracurricular athletic activities.(1) The plan shall be developed by the students teachers,

the students guidance counselor, school nurse,certied athletic trainer i on sta, neuropsychologisti available or involved, parent, members o thebuilding-based student support and assistance team or

individualized education program team as appropriateand in consultation with the students primary care

provider or the physician who made the diagnosis orwho is managing the students recovery.

(2) The written plan shall include instructions or students,parents and school personnel, addressing but notbe limited to: (a) Physical and cognitive rest asappropriate; (b) Graduated return to extracurricularathletic activities and classroom studies as appropriate,including accommodations or modications as needed;(c) Estimated time intervals or resumption o activities;

(d) Frequency o assessments, as appropriate, by theschool nurse, school physician, team physician, certiedathletic trainer i on sta, or neuropsychologist iavailable until ull return to classroom activities andextracurricular athletic activities are authorized; and(e) A plan or communication and coordination betweenand among school personnel and between the school, the

parent, and the students primary care provider or the



39/68

ovrviw:I a stdent athlete has been diagnosed with a concssion, the regla-

tions reqire that a gradated reentry plan, or both academics and

sports, be developed and implemented. Recovery rom a concssion

reqires rest, both physical and cognitive, in order or the brain to heal.

This means that dring the recovery period, it is as important or a

concssed stdent to rerain rom stdying, working on a compter or

playing video games, as it is or the stdent to rerain rom participat-ing in athletics. A gradated reentry plan, to either academics or sports,

shold not begin ntil a stdent is symptom-ree at rest. A stdent

shold be symptom-ree at each stage o the plan beore gradating to

the net phase.

Gradated reentry plans reqire a collaborative approach among health

care providers, teachers, gidance conselors, the athletic sta and the

athlete and her/his parent or gardian. Gradated reentry plans inclde

gradal steps rom physical and cognitive rest, gradal retrn to physical

and academic activities, estimated time intervals or resmption o ac-

tivities, reqent assessments, and a commnication plan among school

sta, parents, and health care providers. The injred stdent will recover

more qickly with rest, not only rom physical eertion and athletic activ-

ity, bt also rom the cognitive demands o academic work.

For eample, stdents who retrn to school ater a concssion may need to:

Take rest breaks as needed

Spend ewer hors at school

Be given more time to take tests or complete assignments

Receive help with schoolwork, and/or

Redce time spent on the compter, reading, or writing 25

MDPH has worked with the Department o Elementary and Secondary

Edcation to provide gidance to schools regarding academic accom-

modation options. A link to this gidance can be ond in theAdditional

Resources section.

physician who made the diagnosis or who is managingthe students recovery.

(3) The student must be completely symptom-ree andmedically cleared as dened in 105 CMR 201.011 inorder to begin graduated reentry to extracurricularathletic activities.

25 CDC: Heads up to Schools, Know yor Concssion ABCs, A Fact Sheet or School Nrses

40SECTION 10: DEVELOPMENT AND IMPLEMENTATION OF POST-CONCuSSION GRADuATED REENTRY PLANS


40/68


27 Based on the work o Dr. Janet Kent at Soth Shore Hospital;

see www.sothshorehospital.org/yhc/HeadSmart_Handbook.pd

Graua Rry Pla Sampl 1:________ School reqires that all stdents retrning to school and

athletics ater a concssion have a written plan or reentry. Schoolsta, sch as teachers, school nrses, conselors, administrators,

speech-langage pathologists, coaches and others shold work

together to develop and implement this plan in coordination with the

stdent, their parent/gardian and the primary care provider.

Gradated retrn to academic plans are based on the stages

o recovery ramework that takes a stdent rom rest to gradal

retrn to ll participation in academic activities.26

Stages o Recovery:27

The stages o recovery are a ramework designed throgh a col-

laborative eort by local health care proessionals. The prpose o

A gradated retrn to play (etracrriclar athletic activity) plan shold

involve a stepwise process rom complete rest, to light eercise, to aero-

bic eercise, to no-contact training drills, and nally ll-contact practice

and game play.

The written gradated reentry plan shold be kept in the stdents

medical record in the school health nrse oce and also the athleticdepartment oce. Eamples o both retrn to academics and retrn to

play protocols can be ond in the Sample Policies that ollow.

To comply with the reglations, this section o the schools policies mst

address: which school personnel will be involved in the development o

gradated reentry plans, how parents/gardians will be involved, who will

monitor progress, and where the written plan will be kept.

There is sbstantial feibility that may be incorporated into school/school

district policies and procedres or gradated re-entry based pon localneeds and resorces. This is demonstrated in the sample policies below.

http://www.southshorehospital.org/yhc/HeadSmart_Handbook.pdfhttp://www.southshorehospital.org/yhc/HeadSmart_Handbook.pdf


41/68

Gradated retrn to athletic plans will begin only ater a stdent

has retrned to ll participation in academics and is completely

symptom-ree at rest.

this ramework is to create common langage that will help gide

stdents, amilies, school personnel and health proessionals

throgh the recperation process. Placement in stages is based

on assessment o the stdents medical condition by a licensed

medical proessional and accompanied by written orders.

Red Stage (usally 2 4 days, bt cold last weeks)

Rest

Stdents typically do not attend school

Orange Stage

Rest

Attend school hal to ll days

Avoid school bs and heavy backpacks

Work with designated edcational personnel regarding school

accommodations

No tests in school

No sports, band, chors, physical edcation or otdoor recess

Yellow Stage

Attend school ll-time i possible

Stdents and amilies work with teachers regarding homework

deadlines (complete as mch as possible)

See school nrse or pain management and/or rest i needed

Limit one qiz/test per day (ntimed testing is recommended)

Work in 15 minte blocks

No sports

Licensed medical proessional will make decisions regarding

band, chors, physical edcation and otdoor recess (elemen-

tary level) based on medical assessment

Green Stage

Attend school ll-time

Resme normal activities

Resme sports once school work is back on track, stdent is symp-

tom-ree, and has been cleared by a licensed medical proessional



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Return to Play Schedule:28

When a stdent athlete is completely symptom-ree at rest and

has the approval o a medical proessional, she/he may begin a

gradated retrn to play protocol. The retrn to play schedle or

the stdent shold proceed as ollows and shold be monitored

by the athletic trainer.

Step 1: Light eercise, inclding walking or riding an eercise bike.

No weight-liting.

Step 2: Aerobic eercise sch as rnning in the gym or on the

eld. No helmet or other eqipment.

Step 3: Non-contact training drills in ll eqipment. Weight-training

can begin.

Step 4: Fll-contact controlled training ollowed by practice or

training.

Step 5: Fll-contact game play.

The written reentry plans will be signed by the stdent, their

parent/gardian, the school nrse, the lead teacher/gidance

conselor, athletic trainer and coach so that all parties are in

agreement as to the plan or reentry. Freqent or periodic assess-

ments by the school personnel inclding the nrse, athletic trainer,

school physician or team physician as appropriate may be neces-

sary ntil ll retrn to classroom activities and etracrriclar

athletic activities are athorized by medical sta. A copy o the

plan will be kept in the stdents medical record.

28 Adapted rom Borne School District, Marsheld Pblic Schools and NFHS

29 Adapted rom Northampton High School

Graua Rry Plas Sampl Plicy 2 (thisis a sampl rur play prcl r a schluilizig ImPACt sig r ahls):29

Gradual Return to Play Protocol:

Retrn to play will occr only ater the ollowing steps have beencompleted, in the orderlisted below:

1. Parent/Gardian reads and signs the Concssion Inormation

and Gradal Retrn to Play Protocol.



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Graua Rry Plas Sampl Plicy 3 (thisis a aiial sampl a rur playprcl):30

Following a post-injry test, the certied athletic trainer will take

the Concssion Inormation and Gradal Retrn to Play orm (see

link to this orm inAdditional Resources) signed by the parent(s)

or legal gardian(s) and ll in the date o all post-injry tests

taken by each stdent athlete.

The certied athletic trainer will also docment the date in which

the athlete is asymptomatic and sign the docment agreeing that

all the above statements are tre and accrate.

2. Post injry ImPACT test completed when athlete retrns to

school. Post injry ImPACT test mst be back to baseline

beore contining with the Physical Post Concssion Tests.

Parent/Gardian will be notied, and athlete reerred to their

health care provider, i rst post injry ImPACT test is not back

to baseline. Post-injry ImPACT test will contine every ve(5)

days ntil baseline is attained.

3. Athletic trainer veries that the Physical Post Injry Tests were

administered and the athlete was asymptomatic. Athlete

mst nish Physical Post Injry Tests, even i athlete has been

cleared by their health care provider.

4. Athlete may not participate in practice or play ntil written

clearance by an appropriate health care proessional: physi-

cian (MD, DO) or nrse practitioner (NP)AND with completion

o the Physical Post Injry Tests.

5. Completed signatre orm retrned to athletic trainer.

6. Athlete reads and signs the Concssion Inormation.

7. Athletic trainer noties coach and gives copies o completed

orm to director o athletics and school nrse.



44/68

Beore the athlete starts on the eertional post concssions tests,

the parents will be notied and the athlete will be sent home

with all signed docments relating to head injry. At this time, the

parent(s) or legal gardians mst bring their stdent athlete to an a

licensed physician, licensed neropsychologist, nrse practitioner or

other appropriately trained or licensed healthcare proessional to be

cleared or participation in their etracrriclar activity. Alternatively,

the certied athletic trainer may coner with the athletes healthcare

provider to obtain clearance or beginning the gradated reentry

plan. Stdent athletes will also need to receive nal medical clear-

ance or Retrn to Play ater they have completed their gradated

re-entry plan. This medical clearance may only be provided by a

licensed physician, neropsychologist, nrse practitioner, or certied

athletic trainer.

Student athletes who continue to exhibit concussion symptoms

or a week or more must be evaluated by a physician beore

returning to play.

Once a stdent athletes post-injry test is back at the stdent

athletes baseline score they will go throgh 5 days o Eertional

Post Concssion Tests. The stdent athlete mst be asymptomatic

or all nctional and physical tests to retrn to play (RTP). All tests

will be administered by a certied athletic trainer.

Exertional Post Concussion Tests:

Test 1: (30% to 40% maimm eertion): Low levels o light physi-cal activity. This will inclde walking, light stationary bike or abot

10 to 15 mintes. Light isometric strengthening (qad sets, uE

light hand weights, ham sets, SLRs, resistive band ankle strength-

ening) and stretching eercises.

Test 2: (40% to 60% maimm eertion): Moderate levels o

physical activity. Treadmill jogging, stationary bike, or elliptical or

20 to 25 mintes. Light weight strength eercises (resistive band

eercises uE and LE, wall sqats, lnges, step p/downs). More

active and dynamic stretching.

Test 3: (60% to 80% maimm eertion). Non-contact sports spe-cic drills. Rnning, high intensity stationary bike or elliptical 25 to

30 mintes. Completing reglar weight training. Start agility drills

(ladder, side shfe, zig-zags, carioca, bo jmps, and hrdles).

Test 4: (80% maimm eertion). Limited, controlled sports spe-

cic practice and drills.

Test 5: Fll contact and retrn to sport with monitoring o symptoms.



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Graua Rry Plas Sampl Plicy 4 (this is a xampl a rur play prcl ha iclus a sigaur rm h par, ahlic rair asu h sam rm):

Northampton High School, Department o Athletics: CONCUSSION AND RETURN TO PLAY PROTOCOL

Physical Post Concssion Tests

The athlete will be given ve physical post concssion tests administered by a certied athletic trainer.

Only one test per day. Net test will be administered only when previos test is passed with no symp-

toms. These tests will take a minimm o ve days.

Test 1: (To increase heart rate) Low levels o physical activity. This incldes walking, light jogging, light

stationary biking and light weight liting (low weight, moderate reps, no bench, no sqats).

Test 2: (To increase heart rate with movement) Moderate levels o physical activity with body/head

movement. This incldes moderate jogging, brie rnning, moderate intensity on the stationary cycle,

moderate intensity weight liting (redce time and or redces weight or the athletes typical rotine.

Test 3: Heavy non-contact physical activity. This incldes sprinting/rnning, high intensity stationary cy-

cling, completing the reglar weight liting rotine, non-contact sport specic drills (agility with 3 planes

o movement).

Test 4: Sports specic practice.

Test 5: Fll contact in a controlled drill or practice.

Athletes Name__________________________ Age____ Date o Injry______ Sport___________

Parent/Guardian Signature:

I have read the Concussion and Return to Play Protocol and I nderstand the seriosness o a concs-sion, its symptoms and the Graduated Return to Play Protocol. Qestions? Call high school nrse at

413-587-1460 or athletic oce at 413-587-1356.

Parent/Gardian Signatre__________________________________ Date__________

Test Completion Dates with Asymptomatic Results:

Test 1_________ Test 2_________ Test 3_________ Test 4_________ Test 5_________

I veriy that ___________________________ (athletes name) has completed the ve physical post-

concssion tests and said athlete was asymptomatic or all tests.Certied Athletic Trainer Signatre____________________________ Date__________

Athlete Signature

I have read and nderstand the Concussion and Return to Play Protocol, concssion symptoms, and the

seriosness o a second concssion injry.

Athlete Signatre____________________________ Date__________



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Rgulai 105 CMR 201.006(A)(11):Procedure or providing inormation, and necessary ormsand materials, to all parents and athletes including the: (a)annual training requirement, (b) procedure or the schoolto notiy parents when an athlete has been removed romplay or a head injury or suspected concussion sustainedduring an extracurricular athletic activity, (c) protocol or

obtaining medical clearance or return to play and academicsater a diagnosed concussion, (d) parents responsibility orcompletion o the Pre-participation Form, or school-based

equivalent, and (e) parents responsibility or completion othe Report o a Head Injury Form, or school-based equivalent.

Sci 11:

Prviig Irmai,Frms a Marials

Pars a Ahls

11a) Aual traiig Rquirm

ovrviw:The MDPH reglations reqire that parents or legal gardians andstdents who participate in etracrriclar athletic activity, as well as a

variety o school personnel, receive MDPH-approved concssion train-

ing annally. (See Section 2 or details abot training reqirement and

Additional Resources or links to approved training materials.) I schools

wish to, they can provide this training in a pre-season meeting or par-

ents and stdents. There are at least two strategies or providing sch

training in a pre-season meeting:

Schools may oer one o the ollowing on-line trainings: the Centers or

Disease Controls (CDC) Heads Up Concussion training or the National

Federation o State High School Associations (NFHS) Concussion in

Sports What You Need to Knowtraining. Schools may se the agenda

and attendance roster as a record o verication or participants who

are trained in this type o grop setting.

Alternatively, schools may se MDPH approved written training materials

to meet the training reqirement. The versions or parents and stdents

are available in English and Spanish. I schools distribte these training

materials to parents and stdents at a pre-season meeting, all parents



47/68

11b) Prcur r h Schl niy Pars Wh aAhl Has B Rmv

rm Play r a Ha Ijury rSuspc Ccussi

ovrviw:The Department o Pblic Health intends that all stdent athletes and

adlts who are on the eld dring practice or competition will be edcated

31 Adapted rom Cambridge Pblic Schools

Sampl Plicy 1:31Parents/gardians and stdents who plan to participate in any

athletic program at ________ School mst also take a ree on-

line corse. Two ree on-line corses are available and contain all

the inormation reqired by the law. The rst is available throgh

the National Federation o High School Coaches. Yo will need

to click the order here btton and complete a brie inormation

orm to register. At the end o the corse, yo will receive a com-

pletion receipt which shold be provided to the coach or athletic

director as docmentation. The entire corse, inclding registra-

tion, can be completed in less than 30 mintes: www.nhslearn.

com/electiveDetail.asp?corseID=15000. The second on-line

corse is available throgh the Centers Disease Control at: www.

cdc.gov/concssion/Headsup/online_training.html.

and stdents shold be asked to sign an acknowledgement veriying that

they have reviewed the written materials.

There are additional options or providing sch inormation, orms and

materials to parents and athletes inclding:

Mail to parents and stdents prior to school season;

Training materials and orms posted to schools website;Training materials and orms inclded in stdent, parent and/or ath-

letic handbook;

Sending ot email reminders to stdents/parents to lll annal

training reqirement;

Coaches can provide inormation orms and video on concssion training

to stdents in pre-season orientation.

48SECTION 11: PROVIDING INFORMATION, FORMS AND MATERIALS TO PARENTS AND ATHLETES
http://www.cdc.gov/concussion/HeadsUp/online_training.htmlhttp://www.cdc.gov/concussion/HeadsUp/online_training.htmlhttp://www.cdc.gov/concussion/HeadsUp/online_training.htmlhttp://www.cdc.gov/concussion/HeadsUp/online_training.html


48/68

with the same basic inormation abot the signs, symptoms and risks o

concssion. Commnication between amilies, athletic sta and health

care providers is crcial to acilitate a stdents prompt removal rom play

and reerral or medical care and ll recovery ollowing a concssion.32 The

ollowing sample policies emphasize the importance o coordination and

commnication among athletic sta, parents and medical providers.


33 Adapted rom Bridgewater-Raynham Regional School District

34 Adapted rom the Deter and Sotheld Schools

35 Adapted rom Params, New Jersey High School

Sampl Plicy 1:33

The athletic trainer, coach, school nrse and/or volnteers (EMS,

sports physicians) shold promptly inorm the athletes parents

or gardians abot the possible concssion dring the day o the

injry via telephone and/or email and give them the act sheet on

concssions. Give the parents the Report o Head Injry Dring

Sports Season Form (or school-based eqivalent) and eplain to

them they will need to complete it and retrn it to the school. In-

orm the parents that the stdent will have to be medically cleared

by a medical proessional beore retrning to play and the Post-

Sports-Related Head Injry Medical Clearance and Athorization

Form will need to be completed and retrned to the school beore

the stdent can resme play.

Sampl Plicy 2:34

I an athlete sstains a sports-related head injry, inclding a

sspected concssion, the athletic trainer, school nrse, or coachwill notiy parents immediately and appropriate school sta within

24 hors o evalating or learning o the injry. This protocol is the

same or all home and away athletic events.

Sampl Plicy 3:35

The athletic trainer or school nrse/physician will be respon-

sible or contacting the athletes parents and providing ollow-p

instrctions. I the athlete is injred at an away event or i the

athletic trainer is navailable, the coaching sta are responsible

or notiying the athletes parents o the injry and, i warranted,

call or emergency care. The stdent shold be sent home with the



49/68

Sampl Plicy:At ________ School parents and stdents are oriented abot the

protocol on obtaining medical clearance or retrn to play ater a

diagnosed concssion. In addition, or athletic handbook nder

the section or Sports Concssion contains or policies regard-

ing sports concssion inclding obtaining medical clearance ater

a concssion. The website or the school at ..ed nder

the Athletic Department tab has a page on sports concssion

that also details these protocols. Finally, parents and stdents

can always call the athletic department oce at -- or

the school nrse oce at -- to get rther clarication or

ask qestions. No stdent will be allowed to retrn to play athletic

activities ntil the medical clearance orm is signed by athorized

medical proessional, sbmitted and reviewed by the school nrse.

11c) Prcl Fr Pars/Sus obai Mical Clarac rRur Play a AcamicsAr a diags Ccussi

ovrviw:The annal saety training or parents/gardians and athletes who partici-

pate in any etracrriclar athletic activity as well as school policies sholdinorm them o the schools protocol on obtaining medical clearance or

retrn to play. Options or schools to provide this inormation inclde:

Mail to parents and stdents prior to school season;

Medical clearance materials and orms posted to schools website;

Training materials and orms inclded in stdent, parent and/or ath-

letic handbook;

Distribting this inormation at pre-season; parents/stdent meetings,

meetings with coaches, or in school assemblies;

Coaches can provide inormation orms and videos on concssion

training to stdents in pre-season orientation.

S als Sci 8.

Report o Head Injry dring Sports Season Form as well as the

Post Sports-related Head Injry Medical Clearance and Athoriza-

tion Form or school-based eqivalents.

50SECTION 11: PROVIDING INFORMATION, FORMS AND MATERIALS TO PARENTS AND ATHLETES


50/68

11) Pars Rspsibiliy rCmpli h Pr-ParicipaiFrm r Schl-Bas equival

ovrviw:The athletic director, coach, school nrse, athletic trainer or other desig-

nated school ocial are responsible or inorming parents and stdents

that the pre-participation orm (or school-based eqivalent) needs to

be completed by the stdent and parent/gardian and retrned to the

athletic director, coach, school nrse, athletic trainer or other designated

school ocial prior to the start o each sports season a stdent plans to

participate. Schools have the ollowing options to edcate stdents and

parents/gardians abot the reqirement to complete the pre-participa-

tion orm, and to provide the orm:

Mail to parents and stdents prior to school season

Training materials and orms posted to schools website

Training materials and orms inclded in stdent, parent and/or ath-

letic handbook

Sending ot email reminders to stdents/parents to lll annal

training reqirement

Providing this inormation at pre-season parents/stdent meetings or

meetings with coaches

Providing this inormation in school assemblies

Coaches can provide inormation orms and video on concssion train-

ing to stdents in pre-season orientation

A link to the MDPH Pre-Participation Head Injury/Concussion Report-

ing Form can be located in theAdditional Resources section.

Sampl Plicy:At ________ Schools annal meeting in the all, parents and

stdents are oriented abot the reqirement to sbmit the pre-

participation orm or school-based eqivalent, signed by both

stdent and parent, which provides a comprehensive history with

p-to-date inormation relative to concssion history. It is the

parents responsibility to tell all the stdents coaches and school

nrse i the stdent has ever had a concssion via this orm. In

addition, or athletic handbook nder the section or Sports

Concssion incldes or policies regarding sports concssion

inclding the reqirement to complete the pre-participation orm



51/68

11) Pars Rspsibiliy rCmpli h Rpr aHa Ijury Frm, r Schl-Bas equival

ovrviw:Options or edcating parent/gardians abot the reqirement to

complete the Report o Head Injury During Sports Season Form (or

school-based eqivalent) are:

The School Nrse or other designated school ocial shold track these

orms and contact parents i they have not yet been retrned

Mail to parents and stdents prior to school season

Training materials and orms posted to schools website

head injury reg guide acc

Documents