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  • H.D Jacobs High School

    Concussion Cover page

    Action/Step Date ATC Initials


    Parent Info


    Phone # _______________

    Physician Visit


    ImPACT baseline Y/N Normal post-injury:

    Step 1: Bike

    Step 2: Running

    Step 3: Agility/Sports Specific


    Step 4: Non-contact practice

    Step 5: Contact Practice

    Cleared for RTP


    Athletic Trainer ______________________________________ Date:______________

  • SCAT5 #: _____________


    Name: ___________ _______ _________ _______________

    DOB: ____________________________ _________ ______

    Parent Name/Phone #: _______________________________________ _________

    School/Sport: ____________________________ ________

    Current Grade: ___________________________ ________

    Gender: M / F / Other

    Dominant Hand: Left / Neither / Right

    How many diagnosed concussion has the athlete had in the past? ____________________ _____ __________

    When was the most recent concussion? ________________________________________

    How long was the recovery time (time to being cleared to play) from the most recent concussion? __________________________ ( days / weeks )

  • SCAT5 #: ___________ __


  • Attention parents/ guardians:

    Unfortunately your child has sustained a head injury/ concussion the following packet has been put together to provide you

    with all the information regarding the next steps in the concussion policy.

    Pages 1-2: General information regarding concussion and the return to play process. This info packet provides a brief

    overview into the symptoms of concussion and general recommendations for recovery that will be expanded upon by the

    physician you see.

    Page 3: The first page with the D300 logo. IHSA policy and Illinois Law mandates that each athlete treated for a concussion

    must be seen by a physician. This D300 form goes to the physician visit and needs to be filled out by the physician and

    returned to the nurse’s office. You are welcome to take your child to any physician of your choosing however I have listed 3

    doctors I know personally who treat pediatric concussions and are aware of our concussion policy and protocol.

     Dr. Matthew Brandon

    455 Briargate Drive, Suite 100

    South Elgin, IL 60177

    Phone: 847-622-0506

     Dr. Jim Krcik

    Mercyhealth Crystal Lake

    415 Congress Parkway

    Crystal Lake, IL 60014

    Phone: 815-356-7494

     Dr. Pradeep Raju OrthoIllinois 650 S. Randall Rd Algonquin IL 60102 Phone: 779.771.7000

    *If you decide to call one of these physicians please make sure to let them know your child is an athlete at Jacobs High School that way they can get you in the office sooner. Page 4: Our return to play protocol. This protocol is a 5-day gradual increase in activity to return the athlete to their perspective sport in a safe manner. This is not optional it is a school policy. Please bring this outline to the physician office so they know what your child will be doing once cleared to return to sport. Page 5: IHSA Return to Sport Form: Please have the athlete and parent/guardian sign the return to sport form and return it to Maddox Reed, athletic trainer so that the return to sport procedure may be initiated once given clearance by physician. Please feel free to call or email me at any time I understand this is a tough process and a scary injury please allow me to answer and questions or concerns. Thank you,

    Maddox Reed, MS, ATC, LAT

    Head Athletic Trainer - Jacobs High School Affiliate of ATI Physical Therapy Cell: 313-586-2490 email:

  • During today’s practice/game participation your student-athlete sustained a head injury that requires vital monitoring, and

    presents with concussion-like symptoms. Below is a list of signs and symptoms that can occur after sustaining such an

    injury. Symptoms may show up immediately following the injury or in some cases several hours later. If any of the signs

    and symptoms listed below present the athlete should seek immediate medical attention. If you are questioning whether to

    seek medical attention, it is recommended that you do so immediately.

    The following signs and symptoms (complaints) mandate immediate emergency room evaluation:

    *Headaches that significantly worsen *Looks very drowsy/can’t be awakened *Neck pain

    *Can’t recognize people or places *Repeated vomiting *Seizures

    *Increasing confusion or irritability *Unusual behavioral change *Focal neurologic signs

    *Change in state of consciousness *Weakness or numbness in arms/legs *Slurred Speech

    *Blood or watery fluid from ears or nose *Unequal or dilated pupils *Asymmetry of the face

    General Recommendations:

     Rest is the key. Do not participate in ANY activities if any signs or symptoms exist. Be sure to get enough sleep

    at night – no late nights. Take naps or rest breaks as needed.

     It is important to limit activities that require a lot of thinking or concentration (called cognitive rest), as this can

    make signs and symptoms worse, which may prolong healing. This includes but is not limited to: texting,

    operating a computer, watching television, playing video games and reading.

     With ANY injury, a full recovery will reduce the chances of getting hurt again. Second-Impact Syndrome is

    VERY serious. It is better to miss a few games than to be severely injured for your season, or indefinitely.

     Consult with an athletic trainer as available, or see a physician licensed to practice medicine who is familiar with

    current concussion care and management as soon as possible for proper evaluation and treatment.

    Return to Participation:

    As adopted from the National Federation of High School Sports recommendations: After suffering a concussion, no athlete should

    return to play or practice on that same day. Newer studies have shown that the young brain does not recover quickly enough for an

    athlete to return to activity in such a short time.

    Remember: Please realize head injuries and the study of Mild Traumatic Brain Injury (MTBI), also known as concussion, is continually evolving. ATI Physical

    Therapy strives to use the most-up-to-date information. If you experience signs or symptoms that vary from the above mentioned ones err on the side of caution and

    seek further medical attention from a qualified healthcare provider.


    - “Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport Held in Zurich, November 2012.” Br J Sports Med,


    - National Federation of High Schools (NFHS) Sports Medicine Advisory Committee (SMAC) Guidelines can be found at:

    - Illinois High School Association (IHSA) Sports Medicine Advisory Committee (SMAC) Policy & Resources can be found at:

    - National Athletic Training Association Resource Page can be found at:

  • Date:_______

    Dear Treating Physician,

    Your Patient ___________________________________ is a CUSD 300 student and was injured with symptoms indicating a possible

    concussion. A baseline ImPACT test was completed and a post ImPACT test will be given once the student is symptom free for 24

    hours and is fully active cognitively.

    History: ____________________________________________________________________________________________________________



    Symptoms (Place an X next to all present symptoms):

    Symptom Yes No Symptom Yes No

    Headache Confusion

    Dizziness (Eyes Open) Blurred Vision

    Dizziness (Eyes Closed) Sleep Disturbances

    Nausea Memory Loss (Anterograde)

    Fatigue Memory Loss (Retrograde)

    Irritable Pain

    Sensitivity to Light Loss of Consciousness

    Sensitivity to Sound Other:


    ______ Concussion _______ Head Trauma ________ No Injury

    CUSD 300 recognizes the impact of a concussion and supports full cognitive and physical rest.

    Please circle the Return to Learn step you prescribe for your patient to begin:

    Step Intensity Cognitive Activity Sug


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