Ohio High SchoolAthletic Association Ai

PREPARTICIPATION PHYSICAL EVALUATION 2019-2020HISTORY FORM

(Note: This form is to befilled out by the student andparentprior to seeing the medical examiner.)

Page 1 of 6

Date of Exam

Name Date of birth

Sex Age Grade School Sport(s)

Address

Emergency Contact: Relationship

Phone(H) (W) (Cell) (Email)

MedicinesandAllergies: Pleaselist the prescription and over-the-counter medicines and supplements(herbal and nutritional-including energy drinks/ protein supplements)that you arecurrentlytaking

Doyou have anyallergies? [_] Yes [_]No Ifyes, please identify specific allergy below.

O Medicines O Pollens OFood O Stinging Insects

Explain “Yes” answers below. Circle questions you don't know the answersto.ereQUESTIONS Yes No BONE AND JOINT QUESTIONS - CONTINUED: Yes No

Has a doctor everdeniedorrestricted yourparticipation in sports for any 22. Do you regularly use a brace,ortholics, or otherassistive device?

reason? 23. Do you havea bone, muscle,or jointinjury that bothers you?

2. Do you have any ongoing medical conditions?If so, please identify 24, Do anyof yourjoints becomepainful, swollen, feel warm,orlook red?pe Asthma Anemia Diabetes Infections 25. Do you have anyhistory ofjuvenile arthritis or connective tissue disease?

er:

3. Have you ever spent the night in the hospital? MEDICAL QUESTIONS Yes No

4. Have you everhad surgery? 26. Do you cough, wheeze,or havedifficully breathing during or after exercise?

HEART HEALTH QUESTIONS ABOUT YOU Yes No 27. Have youeverused aninhaler or taken asthma medicine?

5. Haveyou ever passed out ornearly passed out DURING or AFTER 28. Is there anyone in yourfamily who has asthma?

exercise? 29. Were you bom without or are you missing a kidney, an eye, a testicle (males),6. Haveyou everhad discomfort, pain, tightness,or pressure in your chest yourspleen,or any other organ?

during exercise? 30. Do you have groin pain ora painful bulge or hernia in the groin area?

7.___Doesyour heart ever race orskip beats(irregular beats) during exercise? 31. Have you hadinfectious mononucleosis (mono)within the past month?

8. Has a doctor evertold youthat you have any heart problems?If so, check 32. Do you have anyrashes,pressuresores,or otherskin problems?all that apply: 33. Have you had a herpes (cold sores) or MRSA (staph)skin infection?

© Highbloodpressure © A heart murmur 34. Have you everhad a head injury or concussion?

G Highcholesterol © Aheart infection 35. Have you everhad a hit orblowto the headthat caused contusion,

O Kawasaki disease Other: prolonged headaches, or memory problems?

9. Has a doctor everordered test for your heart? (For example, ECG/EKG, 36. Do you havea history of seizure disorderor epilepsy?echocardiogram) 37. Do you have headacheswith exercise?

10. Do you getlightheaded orfeel more short of breath than expected during 38. Have you ever had numbness,tingling, or weaknessin your arms or

exercise? legsafter beinghit or falling?

11. Haveyou ever had an unexplained seizure? 39. Have you ever been unable to move your armsorlegsafter being hit or falling?

12. Do you getmoretired or short of breath more quickly than yourfriends 40. Have you ever becomeill while exercisingin the heat?during exercise? 41. Do you getfrequent muscle cramps when exercising?

HEART HEALTH QUESTIONS ABOUT YOURFAMILY Yes No 42. Do youor someonein yourfamily havesicklecell trait or disease?

13. Has any family memberor relative died of heart problemsor had an 43. Have you had anyproblems with your eyes orvision?unexpected or unexplained sudden death before age 50 (including 44. Have you had aneye injury?drowning, unexplained caraccident, or suddeninfant death syndrome)? 45. Do you wear glassesor contact lenses?

14. Does anyonein yourfamily have hypertrophic cardiomyopathy, Marfan 46. Do you wearprotective eyewear, such as gogglesor a face shield?syndrome,arrhythmogenic rightventricular cardiomyopathy, long QT 47. Do you worry aboutyour weight?

syndrome,short QT syndrome, Brugada syndrome, or catecholaminergic 48. Are youtrying to gain or lose weight? Has anyone recommendedthatyou do?polymorphic ventricular tachycardia? 49. Are youona specialdiet or do you avoid certain types of foods?

15. Does anyonein your family have a heart problem, pacemaker,or implanted 50. Have you everhad an eating disorder?defibrillator? 51. Do you have any concernsthat you would like to discuss with a doctor?

16. Has anyonein your family had unexplained fainting, unexplained seizures, FEMALES ONLY

or near drowning? 52. Have you ever had a menstrual period?

BONE AND JOINT QUESTIONS Yes No 53. Howold were you when you hadyour first menstrual period?

17. Have you ever had an injury to a bone, muscle,ligament, or tendon that 54. How many periods have you had in thelast 12 months?caused you to miss a practice or game?

18. Have you ever had anybrokenorfractured bonesordislocated joints? Explain "yes" answers here

19. Have you everhadaninjury that required x-rays, MRI, CTscan,injections,therapy, a brace,a cast, or crutches?

20. Have you ever hada stressfracture?21. Have you everbeentold that you have or haveyou had an x-ray for neck

instability or allantoaxialinstability? (Down syndromeor dwarfism)

I herebystatethat, to the best of my knowledge, my answersto the above questions are complete and correct.

Signature of Student, Signature of parent/guardian,

The student has family insurance oO Yes Oo No _lfyes, family insurance company nameandpolicy number:

Date:

©2010 American Academyof Family Physicians, American AcademyofPediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academyof Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13

Ohio High School Athletic Association

PREPARTICIPATION PHYSICAL EVALUATION 2019-2020 Page 2 of 6THE ATHLETE WITH SPECIAL NEEDS - SUPPLEMENTAL HISTORY FORM

PLEASE COMPLETE ONLY IF YOUR STUDENT HASSPECIAL NEEDSORA DISABILITY.

Date of Exam

Name Dateof birth

Sex Age Grade School Sport(s)

Type ofdisability

Dateofdisability

Classification(if available)

Causeofdisability (birth, disease, accident/trauma,other)

List the sports you are interestedin playing

sais[win]

Yes No

Do you regularly use a brace,assistive device orprosthetic?

Do youuse a special brace or assistive device for sports?

Do you have anyrashes,pressuresores,oranyotherskin problems?

9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you havea visual impairment?

41. Do you have any special devices for bowelor bladderfunction?

12. Do you have burningordiscomfort when urinating?

13. Have you had autonomic dysreflexia?

14. Have you ever been diagnosedwith a heatrelated (hyperthermia)or cold-related (hypothermia)illness?

15. Do you have muscle spasticity?

16. Do you have frequentseizuresthat cannotbe controlled by medication?

Explain "yes" answers here

PINS

Pleaseindicateifyou have ever had anyofthefollowing.

Yes No

Atlantoaxial instability

X-rayevaluationfor atlantoaxial instability

Dislocated joints (more than one)

Easybleeding

Enlarged spleen

Hepatitis

Osteopenia or osteoporosis

Difficulty controlling bowel

Difficulty controlling bladder

Numbness ortingling in arms or hands

Numbness ortinglingin legsorfeet

Weaknessin arms or hands

Weaknessin legsor feet

Recentchangein coordination

Recentchangein ability to walk

SpinabifidaLatexallergy

Explain "yes" answers here

I herebystate that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of Student. Signature of parent/guardian. Date:

©2010 American AcademyofFamily Physicians, American AcademyofPediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, andAmerican Osteopathic Academy

of Sports Medicine. Permissionis granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13

Ohio High SchoolAthletic Association LiPREPARTICIPATION PHYSICAL EVALUATION 2019-2020 Page3 of 6

PHYSICAL EXAMINATION FORMName Date of birth

PHYSICIAN REMINDERS1. Consider additional questions on more sensitiveissues.

¢ Doyoufeel stressed outor under a lotof pressure?

+ Do you everfeel sad, hopeless, depressed or anxious?

+ Do youfeelsafe at your home orresidence?+ Have youevertried cigarettes, chewing tobacco,snuff, or dip?

+ During the past 30 days, did you use chewing tobacco, snuff, or dip?

+ Doyoudrinkalcoholor use any other drugs?e Haveyou evertaken anabolic steroids or used anyother performance supplement?e Have you evertaken any supplementsto help you gain or lose weight or improve your performance?

« Do you weara seatbelt, use a helmetor use condoms?

e Do you consume energy drinks?2. Consider reviewing questions on cardiovascular symptoms(questions 5-14).

EXAMINATION DATE OF EXAMINATION

Height Weight D Male O Female

BP 1 ( / ) Pulse Vision R 20/ L20/ Corrected OY ON

MEDICAL NORMAL ABNORMALFINDINGS

Appearance

Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span> height, hyperlaxity, myopia, MVP,aortic insufficiency)

Eyes/ears/noselthroat

Pupils equal

Hearing

Lymph nodes

Heart

Murmurs (auscultation standing,supine, +/- Valsalva)

Locationofthe point of maximal impulse (PMI)

Pulses

Simultaneous femoralandradial pulses

Lungs

Abdomen

Genitourinary (malesonly)

Skin

HSV,lesions suggestive of MRSA,tinea corporis

Neurologic

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

Functional

Duckwalk, single leg hop

*Consider ECG, echocardiogram,or referralto cardiology for abnormalcardiachistory or exam.bConsider GU exam ifin private setting. Havingthird part present is recommended.“Considercognitive or baseline neuropsychiatric testing if a history of significant concussion.

©2010 American AcademyofFamily Physicians, American AcademyofPediatrics, American Collegeof Sports Medicine, American Orthopaedic Society for Sports Medicine, andAmerican Osteopathic Academy

of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13

PREPARTICIPATION PHYSICAL EVALUATION 2019-2020 Page4 of 6

CLEARANCE FORMNote: Authorization forms (pages 5 and 6) mustbe signed by both the parent/guardian andthe student.

Name Sex OM OF Age Dateofbirth

C1 Clearedforall sports withoutrestriction

© Clearedforall sports withoutrestriction with recommendationsfor further evaluation or treatmentfor

O Not Cleared

O Pendingfurther evaluation

O Forany sports

O Forcertain sports

Reason

Recommendations.

| have examined the above-named student and completed the pre-participation physical evaluation. The student does not present apparentclinical

contraindicationsto practice and participate in the sport(s) as outlined above. A copyof the physical exam is on record in myoffice and can be madeavailable tothe school atthe requestof the parents. In the eventthat the examination is conducted en masseatthe school, the school administrator shall retain a copy of thePPE.If conditionsariseafter the student has beenclearedforparticipation, the physician may rescind the clearanceuntil the problem is resolved andthe potentialconsequencesare completely explained to the athlete (and parents/guardians).

Nameof physician or medical examiner(print/type) Date of Exam

Address Phone

Signature of physician/medical examiner MD,DO,D.C., P.A. or A.N.P.

EMERGENCY INFORMATION

Personal Physician Phone

In case of Emergency, contact Phone

Allergies.

OtherInformation

©2010 American Academyof Family Physicians, American AcademyofPediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, andAmerican Osteopathic Academy

of Sports Medicine. Permissionis granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13

PREPARTICIPATION PHYSICAL EVALUATION 2019-2020 Page 5 of 6

THE STUDENT SHALL NOT BE CLEAREDTO PARTICIPATEIN INTERSCHOLASTIC ATHLETICSUNTIL THIS FORM HAS BEEN SIGNED AND RETURNEDTO THE SCHOOL

OHSAA AUTHORIZATION FORM 2019-2020

| hereby authorizetherelease and disclosure of the personal health information of ("Student"), as described below, to

("School").

Theinformation described below may be released to the Schoolprincipal or assistant principal, athletic director, coach, athletic trainer, physical education teacher, school nurseor other memberof the School's administrative staff as necessary to evaluate the Student's eligibility to participate in school sponsored activities, including butnot limited tointerscholastic sports programs, physical education classesorother classroom activities.

Personalhealth information of the Student which maybe released anddisclosed includes records of physical examinations performed to determine the Student'seligibility toparticipate in school sponsoredactivities, including but not limited to the Pre-parlicipation Evaluation form orother similar documentrequired by the Schoolprior to determiningeligibility of the Studentto participate in classroom or other School sponsoredactivities; records of the evaluation, diagnosis and treatmentofinjuries which the Student incurredwhile engagingin school sponsoredactivities, including butnot limited to practice sessions, training and competition; and other records as necessary to determine the Student'sphysicalfitness to participate in school sponsoredactivities.

Thepersonalhealth information described above maybe releasedordisclosed to the Schoolby the Student's personalphysician or physicians; a physician orother health careprofessionalretained by the School to perform physical examinations to determine the Student's eligibility to participate in certain school sponsored activities or to providetreatmentto studentsinjured while participating in such activities, whetheror not such physiciansor other health care professionalsare paid for their services or volunteertheirtimeto the School; or any other EMT,hospital, physician orother health care professional who evaluates, diagnoses ortreats an injury or other condition incurred by the studentwhile participating in school sponsoredactivities.

| understand that the School has requested this authorization to release ordisclose the personal health information described aboveto makecertain decisions about the

Student's health andability to participate in certain school sponsored and classroom activities, and that the Schoolis a not a health care provideror health plan covered byfederal HIPAA privacy regulations, and the information described below mayberedisclosed and maynotcontinueto be protectedby the federal HIPAA privacyregulations. |also understandthat the Schoolis covered underthe federal regulations that govern the privacy of educational records, andthatthe personal health information disclosed underthis authorization may be protected by those regulations.

| also understandthat health care providers and health plans maynot condition the provision oftreatment or paymenton thesigningofthis authorization; however, the Student'sparticipation in certain school sponsoredactivities may be conditioned onthe signing of this authorization.

| understand that | may revokethis authorization in writing at any time, exceptto the extentthat action has been taken by a health care providerin reliance on this authorization,

by sending a written revocation to the schoolprincipal (or designee) whose name and address appears below.

NameofPrincipal:

School Address:

This authorization will expire whenthe studentis no longerenrolled as a studentat the school.

NOTE:IF THE STUDENTIS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIANTO BEVALID. IF THESTUDENTIS 18 YEARS OF AGE OR OVER, THE STUDENT MUSTSIGN THIS AUTHORIZATION PERSONALLY.

Student's Signature Birth date of Student, including year

Nameof Student's personalrepresentative,if applicable

| am the Student's (check one): Parent Legal Guardian (documentation must be provided)

Signature of Student's personal representative,if applicable Date

A copyofthis signed form has been provided to the studentor his/her personal representative

©2010 American AcademyofFamily Physicians, American AcademyofPediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academyof Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13

PREPARTICIPATION PHYSICAL EVALUATION 2019-2020 Page 6 of 6

[2019-2020 Ohio High SchoolAthletic Association Eligibility and Authorization Statement

This documentis to be signed bythe participant from an OHSAA memberschoolandbytheparticipant's parent.

Q | have read, understand and acknowledgereceipt of the OHSAA StudentEligibility Guide and Checklist

https:/lwww.ohsaa.org/Portals/0/Eligibility/OtherEligibiltyDocs/EligibilityGuideHS.pdf which contains a summary oftheeligibility rules of the Ohio High

SchoolAthletic Association. | understand that a copy of the OHSAA Handbookisonfile with the principal and athletic administrator and that | may reviewit, in

its entirety,if | so choose. All OHSAA bylawsandregulations from the Handbookare also posted on the OHSAA website at ohsaa.org.

Qi)understand that an OHSAA member school must adhere to all rules and regulations that pertain to the interscholastic athletics programs that the

school sponsors,butthatlocal rules may be morestringent than OHSAA rules.

& | understand thatparticipation in interscholastic athleticsis a privilege nota right.

Student Code of Responsibility

ADAs a student athlete, | understand and acceptthe following responsibilities:

| will respect the rights and beliefs of others and will treat others with courtesy and consideration.

| will be fully responsible for my own actions and the consequencesof myactions.

will respect the property of others.

| will respect and obeythe rules of my school and laws of my community, state and country.

| will show respect to those whoare responsible for enforcing the rules of my school and the laws of

my community, state and country.

46 | understand that a student whose characteror conductviolates the school’sAthletic Codeor School

Code of Responsibility is not in good standing andisineligible for a period as determined bytheprincipal.

¿informed Consent - Byits nature, participationin interscholastic athletics includes risk ofinjury and transmissionofinfectious disease such as HIV and

Hepatitis B. Although serious injuries are not common and therisk of HIV transmission is almost nonexistent in supervised schoolathletic programs,it is

impossible to eliminateall risk. Participants have a responsibility to help reducethatrisk. Participants mustobeyall safety rules, report all physical and

hygiene problemsto their coaches,follow a properconditioning program,and inspecttheir own equipmentdaily. PARENTS, GUARDIANS OR STUDENTS

WHO MAYNOT WISH TO ACCEPTRISK DESCRIBEDIN THIS WARNING SHOULD NOTSIGN THIS FORM. STUDENTS MAY NOTPARTICIPATEIN

AN OHSAA-SPONSOREDSPORT WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN’S SIGNATURE.

@ | understand that in the case of injury or illness requiring treatment by medical personnel and transportation to a health carefacility, that a

reasonable attemptwill be made to contactthe parent or guardianin the caseofthe student-athlete being a minor, butthat, if necessary, the student-athlete

will be treated and transported via ambulanceto the nearest hospital.

Qiconsent to medical treatmentfor the student following aninjury orillness suffered during practice and/ora contest.

To enable the OHSAA to determine whether the herein namedstudentis eligible to participate in interscholastic athletics in an OHSAA memberschool |

consent to the release to the OHSAAany andall portions of school record files, beginning with seventh grade, of the herein named student, specifically

including, without limiting the generality of the foregoing, birth and age records, nameand residence address of parent(s)or guardian(s), residence address of

the student, academic work completed, grades received and attendancedata.

Qh consent to the OHSAA’s useofthe herein named student’s name,likeness,andathletic-related information in reports of contests, promotional

literature of the Association and other materials and releasesrelated to interscholastic athletics.

ESunderstand thatif I drop a class, take course work through College Credit Plus, Credit Flexibility or other educationaloptions,this action could affect

compliance with OHSAA academic standards and myeligibility. | acceptfull responsibility for compliance with Bylaw 4-4-1, Scholarship, and the passingfive

credit standard expressedtherein.

2%| understandall concussions are potentially serious and mayresult in complicationsincluding prolonged brain damage and deathif not recognized

and managedproperly. Further| understandthatif my studentis removedfrom a practice or competition due to a suspected concussion,he or shewill be

unable to return to participation that day. After that day written authorization from a physician (M.D.or D.O.) or an athletic trainer working underthe

supervision of a physicianwill be requiredin orderfor the studentto return to participation.

@ | have read and signed the Ohio Departmentof Health's Concussion Information Sheet and have retained a copy for myself.

By signing this we acknowledge that we have read the above information and that we consentto the herein named student's participation.

*Must Be Signed Before Physical Examination

Student's Signature Birth date Gradein School Date

Parent's or Guardian's Signature Date

©2010 American AcademyofFamily Physicians, American AcademyofPediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy

of Sports Medicine. Permissionis granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13

Ohio Department of Health Concussion Information Sheet

For Interscholastic AthleticsDear Parent/Guardian and Athletes,

This information sheetis provided to assist you and yourchild in recognizing the signs and symptoms of a concussion. Everyathlete is different and respondsto brain injury differently, so seek medical attention if you suspect your child has a concus-

sion. Once a concussion occurs,it is very important your athlete return to normal activities slowly, so he/she does not do moredamagetohis/herbrain.

What is a Concussion?

A concussionis aninjury to the brain that may be caused by a

blow, bump,orjolt to the head. Concussions may also happenafter a fall or hit that jars the brain. A blow elsewhere on thebody can cause a concussion evenif an athlete does not hit

his/her head directly. Concussions can range from mild tosevere, and athletes can get a concussion evenif they are

wearing a helmet.

Signs and Symptomsof a Concussion

Athletes do not have to be “knocked out” to have a concussion.In fact, less than 1 out of 10 concussions result in loss of

consciousness. Concussion symptoms can developright awayor up to 48 hoursafter the injury. Ignoring any signs orsymptoms of a concussion puts your child's health at risk!

Signs Observed by Parents of GuardiansAppears dazed or stunned.

/s confused about assignmentorposition.

Forgets plays.

/s unsure ofgame, score or opponent.Movesclumsily.

Answers questions slowly,

Loses consciousness (even briefly).

Shows behavior orpersonality changes(irritability,

sadness, nervousness, feeling more emotional).

+ Can’trecall events before or after hit orfall,

++

++

++

++

Symptoms Reported by AthleteAny headache or “pressure”in head. (Howbadly it hurtsdoes not matter.)

Nausea or vomiting.

Balance problemsordizziness.

Double or blurry vision.

Sensitivity to light and/or noiseFeeling sluggish, hazy, toggy orgroggy.

Concentration ormemoryproblems.

Confusion.

Doesnot “feel right.”

Trouble falling asleep.

Sleeping more or less than usual.

++

++

++

++

++

+

Be Honest

Encourage your athlete to be honest with you, his/her coachand your health care provider about his/her symptoms. Manyyoung athletes get caught up in the moment and/orfeelpressuredto return to sports before they are ready. It is betterto miss one gamethan the entire season... or risk permanentdamage!

Seek Medical Attention Right Away

Seeking medical attention is an importantfirst step if yoususpector are told your child has a concussion. A

qualified health care professional will be able todetermine how serious the concussion is and whenitissafe for your child to return to sports and other dailyactivities.

+ No athlete should return to activity on the same day

he/she gets a concussion.

+ Athletes should NEVER return to practices/gamesif

they still have ANYsymptoms.

+ Parents and coaches should never pressure anyathlete to return to play.

The Dangersof Returning Too Soon

Returning to play too early may cause Second ImpactSyndrome (SIS) or Post-Concussion Syndrome (PCS).SIS occurs when a second blow to the head happens

before an athlete has completely recovered from aconcussion. This second impact causesthe brain toswell, possibly resulting in brain damage, paralysis, andeven death. PCS can occur after a second impact. PCScan result in permanent, long-term concussion

symptoms. Therisk of SIS and PCSis the reason whyno athlete should be allowed to participate in any

physical activity before they are cleared by a qualifiedhealthcare professional.

Recovery

A concussion can affect school, work, and sports. Alongwith coaches and teachers, the school nurse,athletictrainer, employer, and other school administrators shouldbe awareofthe athlete’s injury and their roles in helpingthe child recover.

During the recovery time after a concussion, physical andmental rest are required. A concussion upsets the waythe brain normally works and causesit to work longer

and harder to complete even simple tasks. Activities thatrequire concentration and focus may make symptomsworse and causethe brain to heal slower. Studies showthat children’s brains take several weeks to healfollowinga concussion.

410 OHIO INJURY PREVENTION

Department of Health PARTNERSHIPInjury Prevention Policy and Advocacy Acton Group

http://www.healthy.ohio.gov/vipp/child/returntoplay/concussion

Rev. 09.16

Returning to Daily Activities

1. Be sure your child gets plenty of rest and enoughsleep at night — no late nights. Keep the samebedtime weekdays and weekends.

2. Encourage daytime naps or rest breaks when yourchild feels tired or worn-out.

3. Limit your child’s activities that require a lot of thinking

or concentration (including socialactivities,homework, video games, texting, computer, driving,job-related activities, movies, parties). Theseactivities can slow the brain’s recovery.

4. Limit your child’s physical activity, especially thoseactivities where anotherinjury or blow to the headmay occur.

5. Have your qualified health care professional checkyour child’s symptomsatdifferent times to help guiderecovery.

Returning to Learn (School)

1. Your athlete may need toinitially return to school on alimited basis, for example for only half-days,atfirst.This should be done under the supervision of aqualified health care professional.

2. Inform teacher(s), school counselor or administrator(s)about the injury and symptoms. School personnel

should beinstructed to watch for:

a. Increasedproblemspaying attention.

b. Increased problems remembering or learning new

information.

c. Longer time needed to complete tasks or assignments.

d. Greaterirritability and decreasedability to cope with

stress.

e. Symptoms worsen (headache, tiredness) when doing

schoolwork.

3. Be sure your child takes multiple breaks during studytime and watch for worsening of symptoms.

4. If yourchild is still having concussion symptoms, he/she may need extra help with school-related activities.

As the symptoms decrease during recovery, the extra

help or supports can be removed gradually.

5. For moreinformation, please refer to Return to Learn on

the ODH website.

Resources

ODHViolence andInjury Prevention Program

Centers for Disease Control and Prevention

National Federation ofState High School Associations

www.nfhs.org

Brain Injury Association of America

www.biausa.org/

Returning to Play

1. Returningto play is specific for each person, depending onthe sport. Starting 4/26/13, Ohio law requires writtenpermission from a health care provider before an athlete canretum to play. Followinstructions and guidance provided bya health care professional. It is important that you, yourchildand yourchild’s coach follow theseinstructions carefully.

2. Your child should NEVERreturn to playif he/shestillhas ANY symptoms.(Be sure that your child doesnot have any symptomsat rest and while doing anyphysical activity and/or activities that require a lot of

thinking or concentration).

3. Ohio law prohibits your child from returning to a

gameorpractice on the same day he/she wasremoved.

4. Besurethat the athletic trainer, coach and physicaleducation teacher are aware of your child’s injury andsymptoms.

5. Your athlete should complete a step-by-step exercise-based progression, underthe direction of a qualifiedhealthcare professional.

6. Asample activity progressionis listed below.Generally, each step should take no less than 24hours so that your child’s full recovery would take

about one weekonce they have no symptomsatrestand with moderate exercise.*

Sample Activity Progression*

Step 1: Low levels ofnon-contact physicalactivity,provided NO SYMPTOMSreturn during or after activity.

(Examples: walking, lightjogging, and easy stationarybiking for 20-30 minutes).

Step 2: Moderate, non-contact physical activity, providedNO SYMPTOMSreturn during or after activity.

(Examples: moderatejogging, briefsprint running,moderate stationary biking, light calisthenics, and sport-

specific drills without contact or collisions for 30-45minutes).

Step 3: Heavy, non-contact physicalactivity, providedNO SYMPTOMSreturn during or after activity.

(Examples: extensive sprint running, high intensitystationary biking, resistance exercise with machines andfree weights, more intense non-contact sports specific

drills, agility training andjumping drills for 45-60minutes).

Step 4: Full contact in controlled practice or scrimmage.

Step 5: Full contact in gameplay.

*If any symptomsoccur, the athlete should drop back tothe previous step andtry to progress again after a 24hourrest period.

http://www.healthy.ohio.gov/vipp/child/returntoplay/concussion

‚Rev. 09.16

Ohio Department of Health Concussion Information Sheet

For Interscholastic Athletics

| have read the Ohio Departmentof Health’s Concussion Information Sheet and

understand that | have a responsibility to report my/my child’s symptoms to coaches,

administrators and healthcare provider.

| also understand that I/my child must have no symptoms before return to play can

occur.

OhioDepartment of Health

Rev. 9.16

Sudden Cardiac Arrest (Lindsay's Law)

Lindsay's Law, Ohio Revised Code 3313.5310, 3707.58 and 3707.59 becameeffectiveon August 1, 2017. In accordancewith this law, the Ohio Department of Health, theOhio Department of Education, the Ohio High School Athletic Association, the OhioChapter of the American College of Cardiology and other stakeholders jointly developedguidelines and other relevant materials to inform and educate students and youthathletes participating in or desiring to participate in an athletic activity and their parentsabout the nature and warning signs of sudden cardiacarrest.

The following resources were developed to implement Lindsay’s Law for parents and/orguardians and student- athletes in grades 7-12 in Ohio schools:

e Required videoo Parents and/or guardians AND student-athletes in grades 7 — 12 are

required to view the required video.o The videois available on the Ohio Department of Health’s website at the

following address: http:/Avww.odh.ohio.gov/landing/Lindsays-Law.aspx.

e Required Sudden Cardiac Arrest_Informational Handouto Parents and/or guardians and student-athletes are required to read the

Sudden Cardiac Arrest informational materials on the next page.

e Required Signature Form

o A parent and/or guardian AND the student-athlete are both required tosign the attached signature form andreturn it to the athletic office.

Sudden Cardiac Arrest and Lindsay’s Law ola(iy

aefor the Youth Athlete and paret/Guar| (

e Lindsay’s Law is about Sudden Cardiac Arrest (SCA) in youth athletes. This law wentinto effect in 2017. SCAis the leading

causeof death in student athletes 19 years of age or younger. SCA occurs whenthe heart suddenly and unexpectedly stops

beating. This cuts off blood flow to the brain and othervital organs. SCAis fatal if not treated immediately.

e “Youth” covered underLindsay's Law areall athletes 19 years of age or youngerthat wishto practice for or compete in

athletic activities organized by a school or youth sports organization.

e Lindsay's Law applies to all public and private schools andall youth sports organizationsfor athletes aged 19 years or

youngerwhetheror not they paya fee to participate or are sponsored by a businessor nonprofit. This includes:

1} Allathletic activities including interscholastic athletics, any athletic contest or competition sponsored byor

associated with a school

2) All cheerleading, club sports and school affiliated organizations including noncompetitive cheerleading

3) All practices, interschool practices and scrimmages

e Any of these things may cause SCA:

1) Structural heart disease. This may or maynot be present from birth

2) Electrical heart disease. This is a problem with the heart’s electrical system that controls the heartbeat

3) Situational causes. These may be people with completely normal hearts whoareeitherare hit in the chestor

develop a heart infection

e Warning signs in your family that you or your youth athlete may be at high risk of SCA:

0 Ablood relative who suddenly and unexpectedly dies before age 50

o Anyofthefollowing conditions: cardiomyopathy, long QT syndrome, Marfan syndrome,or other rhythm problemsof

the heart

e Warning signs of SCA.If any of these things happenwith exercise, see your health care professional:

+ Chest pain/discomfort

e Unexplained fainting/nearfainting or dizziness

e Unexplained tiredness, shortness of breath or difficulty breathing

+ Unusually fast or racing heart beats

e The youth athlete whofaints or passes outbefore, during, or after an athletic activity MUST be removed from the activity.

Before returning to the activity, the youth athlete must be seen by a health care professional and clearedin writing.

e If the youth athlete’s biological parent,sibling or child has had a SCA, then the youth athlete must be removed from activity.

Before returning to the activity, the youth athlete must be seen by a health care professional and clearedin writing.

e Any young athlete with any of these warning signs cannot participatein practices, interschool practices, scrimmages or

competition until cleared by a health care professional.

Departmentof EducationOhio |an" Ohio

Otherreasonsto be seen by a healthcare professional would be a heart murmur,high blood pressure,or prior heart

evaluation by a physician.

Lindsay’s Law lists the health care professionals who may evaluate andclear youth athletes. They are a physician (MD or

DO), a certified nurse practitioner, a clinical nurse specialist or certified nurse midwife. For schoolathletes,a physician's

assistantorlicensed athletic trainer mayalso clear a student. That person mayrefer the youth and family to another

health care providerfor further evaluation. Clearance mustbe providedin writing to the schoolor sportsofficial before theathlete can returnto the activity.

Despite everyone's bestefforts, sometimes a youngathlete will experience SCA.If you have had CPRtraining, you mayknow the term “Chain of Survival.” The Chain of Survival helps anyone survive SCA.

Using an Automated External Defibrillator (AED) can savethelife of a child with SCA. Depending on where a young athlete

is during an activity, there may or may not be an AEDclose by. Many,butnotall, schools have AEDs. The AEDs may be near

the athletic facilities, or they may be closeto the school office. Look aroundat a sporting eventto see if you see one.If youare involved in communitysports,look aroundto seeif there is an AED nearby.

If you witness a person experiencinga SCA:First, remain calm.Follow the links in the Chainof Survival:

“+ Link: Early recognition

e Assess child for responsiveness.Does the child answerif you call his/her name?

e Ifo, then attemptto assess pulse. If no pulseis felt or if you are unsure,call for help “someonedial 911”

“Link 2: Early CPR

+ Begin CPR immediately

«e Link 3: Early defibrillation (whichis the use of an AED)

e fan AEDis available, send someoneto getit immediately. Turn it on, attachit to the child and follow theinstructions

¢ If an AEDis not available, continue CPR until EMS arrives

“+ Link 4: Early advancedlife support and cardiovascular care

e Continue CPR until EMS arrives

Lindsay's Law requires both the youth athlete and parent/guardian to acknowledgereceiptofinformation about Sudden

Cardiac Arrest by signing a form.

_ Sudden Cardiac Arrest and Lindsay’s Law

- Parent/Athlete Signature Form

Whatis Lindsay’s Law? Lindsay’s Law is about Sudden CardiacArrest (SCA) in youth athletes. It coversall athletes 19 years or younger

who practice for or competein athletic activities. Activities may be organized by a schoolor youth sports organization.

Whichyouthathletic activities are includedin Lindsay's law?

e Athletics at all schools in Ohio (public and non-public)

e Any athletic contest or competition sponsored by or associated with a school

e Allinterscholastic athletics, includingall practices, interschoolpractices and scrimmages

+ All youth sports organizations

e Allcheerleading and club sports, including noncompetitive cheerleading

Whatis SCA? SCA is whenthe heart stops beating suddenly and unexpectedly.This cuts off blood flowto the brain and othervital

organs. People with SCAwill die if not treated immediately. SCA can be causedby 1) a structural issue with the heart, OR 2) a heart

electrical problem whichcontrols the heartbeat, OR 3) a situation such as a person whoishit in the chestor a gets a heart infection.

Whatis a warning sign for SCA?If a family memberdied suddenly before age 50, or a family member has cardiomyopathy, long QT

syndrome, Marfan syndromeor other rhythm problemsof the heart.

What symptomsare a warning sign of SCA? A young athlete may have thesethings with exercise:

+ Chest pain/discomfort

+ Unexplained fainting/nearfainting or dizziness

e Unexplained tiredness, shortnessof breathordifficulty breathing

e Unusually fast or racing heart beats

Whathappensif an athlete experiences syncopeorfainting before, during or after a practice, scrimmage, or competitiveplay? The coach MUST removethe youthathlete from activity immediately. The youth athlete MUST be seen andcleared by a health care

provider before returning to activity. This written clearance must be shared with a schoolorsportsofficial.

What happensif an athlete experiences any other warning signs of SCA? The youth athlete should be seenby a health care professional.

Whocanevaluate and clear youth athletes? A physician (MDor DO), a certified nurse practitioner, a clinical nurse specialist,certified nurse midwife. For schoolathletes, a physician’s assistantorlicensedathletic trainer mayalso clear a student. That person

mayrefer the youth to anotherhealth care providerfor further evaluation.

Whatis needed for the youth athlete to return to the activity? There must be clearance from the health care providerin writing.This must be given to the coach and schoolor sportsofficial before returnto activity.

All youth athletes and their parents/guardians must view the Ohio Departmentof Health (ODH) video about Sudden Cardiac Arrest,

review the ODH SCA handoutand thensign andreturn this form.

Parent/Guardian Signature Student Signature

Parent/GuardianName(Prind Sn

Diee Departmentof Education

Department Oh7of Health 10