required medical and insurance documents for student athletes · required medical and insurance...
TRANSCRIPT
Required Medical and Insurance Documents for Student Athletes
Coffeyville Community College’s insurance requires the College to have information on file for each athlete. The Insurance Information must be filled out completely. An athlete must have the appropriate forms on file with the Coffeyville Community College Athletic Training Department prior to the first day of practice/participation. If the athlete does not have association with parents, it should be noted on the Medical Insurance Questionnaire by the parent’s name. An athlete may not practice and/or participate in his/her chosen sport until the following information has been received by the CCC Athletic Training Department.
1. Physical – CCC Athletic Medicine-Medical Evaluation a. Each Student Athlete is required to have a Physical Examination administered by a qualified health
care professional (specifically an M.D, D.O., Physicians Assistant, Nurse Practitioner) prior to arrival on campus and prior to the first practice, for each academic year in which they practice/compete/participate
2. Copy of Insurance card –(front & back) – which the athlete is covered
3. Coffeyville Community College Insurance Information (Filled out completely) / Athlete’s Personal Data
4. CCC Medical History Questionnaire
5. “Standing” Pre-Incident Form/Letter (if possible) – from Physician or Insurance company
6. CCC Athletic Insurance Information Document
7. Assumption of Risk and Release of Liability
8. Reading and Signature of the Post Participation Physical (2 pages)
9. Forewarning of Risk Form
10. Concussion Fact Sheet
11. Student Athlete Concussion/Injury and Illness Reporting Acknowledgment and Responsibility Form
12. Athletic Training Sickle Cell Trait Testing Guidelines
13. Athletic Training Room Rules (3 pages)
Thank you for your attention to this sensitive matter for your Athletic Student. If you have any questions about the forms, please contact us as soon as possible. Please return all forms to your coaches or to the athletic training staff. Erin Macaronas, Head Athletic Trainer 620.252.7116 Fax – 620.252.7098
Dat
e:
Rev
. 03
/06/
12
CC
C A
TH
LE
TIC
ME
DIC
INE
- M
ED
ICA
L E
VA
LU
AT
ION
NA
ME
R
AC
E
AG
E
DA
TE
OF
BIR
TH
S
PO
RT
HO
ME
AD
DR
ES
S
TE
L. N
O.
CIR
CL
E C
OL
LE
GE
YE
AR
12
3
CO
FF
EY
VIL
LE
AD
DR
ES
S
TE
L. N
O.
HIG
H S
CH
OO
L A
TT
EN
DE
D
PA
RE
NT
OR
GU
AR
DIA
N
AD
DR
ES
S
TE
L. N
O.
FA
MIL
Y P
HY
SIC
IAN
A
DD
RE
SS
T
EL
. NO
.
CIR
CL
E:
SIN
GL
E
MA
RR
IED
D
IVO
RC
ED
W
IDO
WE
D
MA
LE
F
EM
AL
E
S
OC
IAL
SE
CU
RIT
Y N
O.
ME
AS
UR
EM
EN
TS
AN
D O
TH
ER
FIN
DIN
GS
1. H
EIG
HT
2.W
EIG
HT
3. B
LO
OD
PR
ES
SU
RE
(A
rm a
t h
eart
lev
el)
Sys
toli
c
Dia
stol
ic
4. P
UL
SE
(A
rm a
t h
eart
lev
el)
5. D
IST
AN
T V
ISIO
N
Rig
ht 2
0/C
orr.
To
20/
Lef
t 2
0/C
orr.
To
20/
CL
INIC
AL
EV
AL
UA
TIO
N
(Ch
eck
each
ite
m i
n ap
pro
pri
ate
colu
mn)
Nor
mal
ente
r “N
E”
if n
ot e
valu
ated
Abn
orm
al
6.
Ear
s -
Gen
eral
(In
t. &
Ext
. C
anal
s)
7.
Eye
s -
Ocu
lar
Mo
tili
ty -
Pu
pils
8.
Nos
e
9.
Mo
uth
& T
hroa
t
10. A
bdo
men
& V
isce
ra
11. G
enit
alia
12. H
eart
13.L
ungs
& C
hest
Not
es:
(Des
crib
e ev
ery
abn
orm
alit
y in
det
ail.
En
ter
pert
inen
t
item
nu
mbe
r b
efor
e ea
ch c
omm
ent.
)
OR
TH
OP
ED
IC E
VA
LU
AT
ION
(Che
ck e
ach
item
in
app
rop
riat
e co
lum
n)
Nor
mal
ente
r “N
E”
if n
ot e
valu
ated
Abn
orm
al
14. N
eck
15. U
ppe
r E
xtre
mit
ies
16. L
ow B
ack
17. L
ower
Ext
rem
itie
s
18. K
nee
19. A
nkle
Not
es:
(Des
crib
e ev
ery
abn
orm
alit
y in
det
ail.
En
ter
pert
inen
t
item
nu
mbe
r b
efor
e ea
ch c
omm
ent.
)
X-R
AY
RE
QU
ES
T
UR
INA
LY
SIS
Des
igna
te b
y ea
ch w
ith
neg
ativ
e (-
), p
osi
tive
(+
), o
r tr
ace
(T).
Pro
tein
Glu
cose
Blo
od
CO
NS
EN
T T
O R
EL
EA
SE
ME
DIC
AL
INF
OR
MA
TIO
N
I
he
re
by
auth
oriz
e an
y m
edic
al p
erso
nne
l, in
sura
nce
com
pany
, ph
ysic
ian,
hos
pita
l, a
thle
tic
trai
ner,
dea
n of
stu
den
ts,
coac
hes
or o
ther
pers
ons
who
hav
e at
tend
ed o
r ex
amin
ed th
e cl
aim
ant t
o di
sclo
sean
y in
form
atio
n w
ith
resp
ect
to a
ny i
nju
ry,
poli
cy c
over
age,
med
ical
hi
sto
ry,
con
sult
atio
n,
pres
crip
tio
n,
trea
tmen
t or
reha
bili
tati
on a
nd c
opie
s of
all
med
ical
rec
ords
.
Sig
natu
re
EX
AM
INA
TIO
N R
ES
UL
TS
Acc
epte
d
Rej
ecte
d
Exp
lain
rea
sons
for
rej
ecti
on:
Tra
iner
Phy
sici
an -
(M
D, D
O,
Ph
ysic
ian
s A
ssis
tant
, Nur
se P
ract
itio
ner)
C
offe
yvil
le C
om
m un
ity
Col
lege
/ 4
00 W
est
11th
Cof
feyv
ille
, KS
673
37 /
620
.25
1.7
700
Th
is s
ecti
on M
US
T b
e co
mpl
eted
by
MD
, DO
, Ph
ysic
ian
s A
ssis
t. o
r N
urs
e P
ract
itio
ner
EXAMPLECopy of Insurance Card
Front of Insurance Card:
Employee PerferredMedical, Dental & Vision Community Choice PPOIdentification Card
Group #Employee 9999First name Lastname ID #
123 45 6789
Back of Insurance Card:
Form 2-A
COFFEYVILLE COMMUNITY COLLEGE Form 3-A Insurance Information August 2019/May 2020
SECTION A ATHLETE’S PERSONAL DATA SPORT ____________________ Name _____________________________________________________________ SS# ____________________________
Last First Middle Date of Birth ________________________ Sex ____ Home Phone __________________ Cell Phone ________________ Home address ______________________________________________________________________________________ Street City State Zip Local address _______________________________________________________________________________________
Street City State Zip SECTION B INSURANCE INFORMATION Please circle the appropriate response: 1. Do you have Medical Insurance? Yes No
IF YES, PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD. 2. Are you covered by: Parent's policy Own 3. Is this a managed health care plan? i.e. HMO or PPO Yes No SECTION C STATEMENT OF PARENT OR GUARDIAN OR SPOUSE Must be filled out completely, even if you do not have medical insurance. Father's name __________________________ Home address __________________________________________________ City State Zip
Father’s date of birth __________________ Email address __________________________________________________
Mother's name __________________________ Home address __________________________________________________ City State Zip
Mother’s date of birth __________________ Email address __________________________________________________ Spouse's name __________________________ Home address __________________________________________________ City State Zip
Spouse’s date of birth _________________ Email address _________________________________________________ EMPLOYER INFORMATION
Father's employer ______________________________________ Home phone _____________ Cell phone ____________ Employer' address ______________________________________ Bus. phone ______________ Mother's employer _____________________________________ Home phone ______________Cell phone ____________ Employer' address _____________________________________ Bus. phone _______________ Spouse's employer _____________________________________ Home phone ______________Cell phone ____________ Employer' address _____________________________________ Bus. phone _______________ SECTION D ATHLETIC INJURY INSURANCE LETTER I hereby acknowledge that I have received and read the Coffeyville Community College's Athletic Injury Insurance participant’s information packet. I understand the extent of the College's responsibility to an athlete who becomes injured as a result of participation in the intercollegiate sports program at Coffeyville. I also understand there is an assumed risk involved in playing intercollegiate athletics. I hereby authorize any medical personnel, insurance company, hospital, physician, Athletic Trainer, Dean of Students, coaches, Athletic Director or other person who has attended or examined the claimant to disclose any information with respect to any injury, policy coverage, medical history, consultation, prescription, treatment or rehabilitation and copies of all medical records. A photo static copy of this authorization shall be considered as effective and valid as the original. PERMISSION IS HEREBY GIVEN FOR EMERGENCY TREATMENT, FOR ROUTINE IMMUNIZATIONS, X-RAYS OR TESTS FOR DIAGNOSIS AND HOSPITALIZATION IN CASE OF SERIOUS ACCIDENT OR ILLNESS. ALL OF THE ENCLOSED QUESTIONS HAVE BEEN ANSWERED COMPLETELY AND TRUTHFULLY TO THE BEST OF MY KNOWLEDGE. BOTH SIGNITURES ARE REQUIRED!! _________________________________ _________________________________ Signature of Parent/Guardian Student’s Signature SECTION E IN CASE OF EMERGENCY CONTACT Name _______________________________ Relationship ___________________ Phone (H) ______________ (W) _____________ Address/City/State/Zip _________________________________________________________________________________________
August 2019 - May 2020Coffeyville Community College Medical History Questionnaire
This Medical History Form must be completed annually by the student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
Student’s Name ______________________________________ Male □ Female □ Date of Birth ____________ Sport _______________________
Local Address____________________________________________________________________________ Phone _____________________________
In case of emergency contact:
Name _____________________________________Relationship __________________Phone (H) _________________ (W) __________________
Street City State Zip
Explain “Yes” answers in the box below**. Circle questions you don’t know the answers to. Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include a physical examination.
1. Have you had a medical illness or injury since your last check up or sports physical?
2. Have you been hospitalized overnight in the past year? Have ever had surgery?3. Have you ever passed out during or after exercise? Have you ever had chest pain during or after exercise? Do you get tired more quickly than your friends do during
exercise? Have you ever had racing of your heart or skipped heart-
beats? Have you had high blood pressure or high cholesterol? Have you ever been told you have a heart murmur? Has any family member or relative died of heart problems or
of sudden unexpected death before age 50? Has any family member been diagnosed with enlarged heart,
hypertrophic cardiomyopathy, long QT syndrome, Marfan”s syndrome, or abnormal heart rhythm?
Have you had a severe viral infection (for example, myocardi-tis or mononucleosis) within the last month?
Has a physician ever denied or restricted your participation in sports for any heart problems?
4. Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious, or
lost your memory? If yes, how many times? _________________ When was the last concussion? _________________ How severe was each one? (explain below) Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in your arms, hands,
legs, or feet? Have you ever had a stinger, burner, or pinched nerve?5. Are you missing any paired organs?6. Are you under a doctor’s care?7. Are you currently taking any prescription or non-prescription
(over-the-counter) medication or pills or using an inhaler?8. Do you have any allergies (for example, to pollen, medicine,
food, or stinging insects)?9. Have you ever been dizzy during or after exercise?10. Do you have any current skin problems (for example, itching,
rashes, acne, warts, fungus, or blisters)?11. Have you ever become ill from exercising in the heat?12. Have you had any problems with your eyes or vision?
13. Have you ever gotten unexpectedly short of breath with exercise?
Do you have asthma? Do you have seasonal allergies that require medical treat-
ment?14. Do you use any special protective or corrective equipment
or devices that aren’t usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)?
15. Have you ever had a sprain, strain, or swelling after injury? Have you broken or fractured any bones or dislocated any
joints? Have you had any other problems with pain or swelling in
muscles, tendons, bones, or joints? If yes, check appropriate box and explain below.
16. Do you want to weigh more or less than you do now? Do you lose weight regularly to meet weight requirements
for your sport?17. Do you feel stressed out?18. Have you ever been diagnosed with or treated for sickle cell
trait or sickle cell disease?Females Only19. When was your first menstrual period? When was your most recent menstrual period? How much time do you usually have from the start of one
period to the start of another? How many periods have you had in the last year? What was the longest time between periods in the last year?
□ Head□ Neck□ Back□ Chest□ Shoulder□ Upper Arm
□ Elbow□ Forearm□ Wrist□ Hand□ Finger
□ Hip□ Thigh□ Knee□ Shin/Calf□ Ankle□ Foot
□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □
□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □
□ □□ □□ □□ □
□ □□ □□ □
□ □□ □□ □□ □____________________
Explain “YES” answers below (attach another sheet if necessary)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Student Signature_______________________________________________________________________________________________ Date _____________________________
Yes No Yes No
Form 4-ARev 4/16
August 2019/May 2020 Dear Parent/Guardian: Today, most health care insurance involves some form of managed care like an HMO/PPO-type of coverage. Many of these polices will not cover treatment outside of the service area without a referral. Therefore, it could be very beneficial to your son/daughter to have a “standing” Pre-Incident Form/Letter on file with us in case of an injury/illness. Insurance companies will not give a referral to the College. Many companies provide their own referral form and/or will provide a list of contracted health care providers. Supplying CCC with this information, along with the athlete’s health history, would be of great help. Below is an example of a simple request a parent/guardian could write to their Primary Care Physician or insurance company for the preferred information. To Whom It May Concern: My son/daughter will be attending Coffeyville Community College on an Athletic scholarship beginning August 2018. He/she will be away from home and out of your service area from August 2018 until May 2019. I am asking you for a “standing” pre-incident referral/letter in the event he/she gets sick or injured and would need to seek medical care while attending Coffeyville Community College.
6
IMPORTANT INSURANCE INFORMATION ATHLETES AND PARENTS/GUARDIANS
PLEASE READ Coffeyville Community College Athletic Insurance Information
August 2019/May 2020 The general health of all of our students at CCC is of great importance to us. In cooperation with area physicians and medical facilities, the College has agreed to gather information pertaining to our student-athletes in order to expedite service to them in the event of an illness or accident during their time at CCC. This information allows CCC to assist a health care provider in caring for your son/daughter should the need arise. Coffeyville Community College provides secondary insurance for athletic injuries only. The college is not responsible for a students’ illness or injury, which is not sport-related, or for any pre-existing sports injury or medical bills associated with a pre-existing injury. The secondary insurance pays what is “reasonable and customary” any charges that are over the reasonable and customary cost are the parents/guardians responsibility. Secondary insurance means all medical bills must be submitted to the parent’s insurance first. When an athlete is referred to a doctor or hospital, the athlete’s insurance information is supplied to the entity for filing with the parent’s insurance company. If the physician or medical facility does not file the bill with the parents’ insurance company it will be the parent’s responsibility to file the bill. If CCC should receive a bill, it will be forwarded to the parents for filing. CCC will not file claims with a parent’s insurance company. All medical bills need to be filed with CCC and/or the insurance representative within a timely manner. For the first visit the bills have to be filed within 30 days of the date of injury. All bills must be submitted within 60 days after the proof of loss. Any bill after this time may not be approved by the insurance company. Those bills will then become the sole responsibility of the parent/guardian and/or athlete. Once a parent/guardian has received the EOB (explanation of benefits) and bill from their insurance company, copies of both documents should be submitted to the CCC Insurance Claim Processor. Upon receiving this information, CCC will file the appropriate paperwork with its secondary insurance company for payment of the remaining balance. If the insurance company makes payment directly to the parent/guardian, it is their responsibility to submit payment to the entity that performed the services. It is the responsibility of an athlete and/or parent/guardian to inform CCC of any changes in their insurance. Failure to do so will make the athlete’s bill(s) the full responsibility of said parent/guardian. CCC will not accept responsibility for a student-athletes’ bill(s) when the parent/guardian has supplied false information or indicated no insurance coverage when in fact coverage exists. It is the responsibility of the student-athlete to report any sports-related injury to the CCC Athletic Trainer as soon as possible. The trainer will then determine if the athlete can be treated on campus or should be referred to other specialists. If an athlete goes to the doctor without the consent of a CCC certified trainer, except in a sports emergency, the expenses associated with such a visit become the sole responsibility of the athlete and/or the parents/guardian. A student-athlete will not be excluded from sport participation if he/she has no insurance coverage. CCC’s secondary coverage will take effect provided the athlete and parent/guardian have supplied the needed verification of no insurance coverage. Verification of no insurance means completing all the sections of the Insurance Questionnaire and signing the forms. Please contact the following with any athletic insurance questions: Jana Kastler (620)252-7360 -- Insurance Liaison Erin Macaronas (620)252-7116 -- Athletic Trainer
ASSUMPTION OF RISK & RELEASE OF LIABILITYCOFFEYVILLE COMMUNITY COLLEGE
Any location owned, leased or operated by Coffeyville Community College may involve certain risks and haz-ards that may result in physical injuries to me or even death. I also understand that there are potential risks of which I may not presently be aware.
In consideration for being allowed to utilize the programs, activities, services, facilities, and equipment at Cof-feyville Community College, I understand and realize that my participation in any and all programs or activities is VOLUNTARY.
Additionally I realize that Coffeyville Community College does not insure participants in the above described activities and that any coverage would be through my personal insurance and that CCC has no responsibility or liability for injury resulting from these activities.
I represent that I am in excellent physical condition to participate in the various activities listed in the above paragraphs. I authorize any person connected with the activity or Coffeyville Community College to administer first aid to me, as they deem necessary. I further hereby give my legal consent and authorize any representative of CCC to authorize emergency medical treatment and /or transportation to a medical facility or hospital which may be deemed advisable in the event of injury, accident, or illness during an activity or event at my expense. This release, indemnification and waiver shall be construed broadly to provide a release, indemnification and waiver to the maximum extent permissible under applicable law. A photocopy of this document shall have the same force and effect as the original.
I the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement. I have read this form and fully understand that by signing this form I am giving up legal rights and /or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation.
NAME: ___________________________________________________________________ (PLEASE PRINT)
SIGNATURE: _______________________________________________________ DATE: _______________
SIGNATURE OF PARENT/GUARDIAN_________________________________ DATE: _______________(Required if student is not 18 years of age)
REV 5/1/2018
POST PARTICIPATION PHYSICAL FORM
NAME(Please Print) PHONE NUMBER
Sport DATE
Each student-athlete who has exhausted their eligibility and/or have decided to leave school early, transfer or discontinue athletics will be give the opportunity to complete a post participation physical form within fourteen (14) days.
I understand that if I check one of the following anatomical parts below, that an examination, treatment, and rehabilitation will be provided until I am cleared by the Coffeyville Community College Athletic Training Staff.
The Department of Intercollegiate Athletics will be responsible for payments incurred for up to one calendar year from the onset of the injury; provided I am not actively engaged in athletic competition in professional sports, international games, or any other form of organized athletics, or as deemed necessary by the Coffeyville Community College Athletic Training Staff.
I understand that If I have not checked one of the anatomical parts listed below, Coffeyville Community College will not be responsible for any injury sustained after today. Failure to complete a post participation physical examination may restrict or eliminate medical coverage or payment, as it related to intercollegiate athletics, for the student-athlete.
Once the form is complete, a certified athletic trainer will schedule an appointment for me with the Coffeyville Community College team physician if needed.
________ I have no injuries at this time
________ Head
________ Neck
________ Chest / Ribs
________ Upper Back / Spine
________ Lower Back / Spine
________ Hip / Pelvis
________ Thigh / Groin / Hamstring
________ Knee
________ Lower Leg
________ Foot / Ankle
________ Shoulder
________ Elbow / Forearm
________ Hand / Wrist / Thumb
________ Internal / Other _____________________
Student-Athlete Signature ________________________________________ Date _______________________
Ceritified Athletic Trainer Signature ________________________________ Date _______________________
6/2/2014
Body Part:
Diagonisis
Diagonstic Test
Medication
Further Recommendations
Cleared: Yes / No Physicians’ Signature _____________________________________ Date_________
Body Part:
Diagonisis
Diagonstic Test
Medication
Further Recommendations
Cleared: Yes / No Physicians’ Signature _____________________________________ Date_________
Body Part:
Diagonisis
Diagonstic Test
Medication
Further Recommendations
Cleared: Yes / No Physicians’ Signature _____________________________________ Date_________
FOREWARNING
This is a warning to you, as a student-athlete, of the risk you take while participating in
sports at Coffeyville Community College. By participating in ______________________ (sport)
at Coffeyville Community College, you may sustain any of the following injuries and others not
included. This list is not conclusive, as there are other injuries which may occur to you while
participating in sports at Coffeyville Community College. This forewarning and list of injuries
is provided to make you aware of the inherent dangers and risks involved while participating in
sports.
1. Head injuries - can result in brain damage, coma and/or death.2. Spine injuries - can result in quadriplegia, paraplegia, and/or death.3. Strains - completely torn, partially torn, and/or stretched muscles or muscle tendons.4. Sprains - completely torn, partially torn, and/or stretched ligaments.5. Contusions.6. Lacerations, abrasions, and other flesh wounds can result in infection.7. Internal organ damage, such as rupture of a spleen or kidney.8. Loss of a limb or vital organ of the body.9. Cartilage damage on the joints of the body.10. Death.
I have read the following, and I understand what it states. I understand that I may suffer an injury as a result of participating in intercollegiate sports at Coffeyville Community College
__________________________________ ____________________________________Print Name Signature
__________________________________ ____________________________________Date Sport/Activity
CONCUSSION: A fact sheet for student athletesWHAT IS A CONCUSSION?A concussion is a brain injury that: Is caused by a blow to the head or body. From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment
such as a bat, lacrosse stick or ball. Can change the way your brain normally works. Can range from mild to severe. Presents itself differently for each athlete. Can occur during practice or competition in ANY sport. Can happen even if you do not lose consciousness.
HOW CAN I PREVENT A CONCUSSION?Basic steps you can take to protect yourself from concussion: Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent and
sticks to the head all cause concussions. Follow your athletics department’s rules for safety and rules of the sport. Practice Good sportsmanship at all times. Practice and perfect the skills of the sport.
WHAT ARE THE SYMPTOMS OF A CONCUSSION?You can not see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.Concussion symptoms include: Amnesia. Confusion. Headache. Loss of conscientiousness. Balance problems or dizziness. Double or fuzzy vision. Sensitivity to light or noise. Nausea (feeling that you might vomit). Feeling sluggish, foggy or groggy. Feeling unusually irritable. Concentration or memory problems (forgetting game plays, facts, meeting times.) Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse.
WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION?Do not hide it. Tell your athletic trainer and coach. Never ignore a blow to the health. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out.
Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the soon-er you may be able to return to play.
Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance.
Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life.
IT IS BETTER TO MISS ONE GAME THAN THE WHOLE SEASON.
WHEN IN DOUBT, GET CHECKED OUT.
For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion.6/2/214
Student-Athlete Concussion/Injury and Illness Reporting Acknowledgment and Responsibility Form
I understand that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to my athletic trainer and/or team physician. I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I acknowledge that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at Coffeyville Community College.
I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. I have been provided with education on head injuries and understand the importance of immediately reporting symptoms of a head injury/concussion to my athletic trainer and/or team physician.
After reading the NCAA Concussion fact sheet, I am aware of the following information:
☐ A concussion is a brain injury, which I am responsible for reporting to my athletic trainer and/or team physician.
☐ A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance.
☐ You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.
☐ If I suspect a teammate has a concussion, I am responsible for reporting the injury to my athletic trainer and/or team physician.
☐ I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.
☐ Following a concussion, the brain needs time to heal. You are much more likely to have repeat concussion if you return to play before you symptoms resolve.
☐ In rare cases, repeat concussions can cause permanent brain damage, and even death.
By signing below, I acknowledge that my institution has provided me with specific educational materials on what a concussion is and given me an opportunity to ask question about areas and issues that are not clear to me on this issue.
I accept the responsibility for reporting all of my injuries and illnesses to the Coffeyville Community Sports Medicine Staff, including signs and symptoms of concussions.
Signature of Student-Athlete ____________________________________________ Date _______________
Printed Name of Student-Athlete _________________________________________
If Student-Athlete is under the age of 18:Signature of Parent or Guardian: _________________________________________ Date _______________
Description of Legal Guardianship.
ATHLETIC TRAINING SICKLE CELL TRAIT TESTING GUIDELINES ABOUT SICKLE CELL TRAIT
Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition (> three million Americans). Although Sickle cell trait is most predominantly in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or “sickle” shape), which can accumulate in the bloodstream and “logjam” blood vessels, leading to collapse from the rapid breakdown of muscles starving of food.
Coffeyville Community College recommends that all student-athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletic event, including strength and conditioning sessions, practice, competitions, etc. Testing is available at your family physicians’ office and results will be reported to Coffeyville Community College Athletic Training department.
Student-athletes will not be allowed to practice until the waiver form is signed and submitted to the Coffeyville Community College Athletic Training Department.
SICKLE CELL TRAIT TESTING WAIVER
I, ________________________________________________________________ understand and acknowledge that the Coffeyville Community College Athletic Training department asks, that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing.
Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to Coffeyville Community College athletic training personnel.
I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless Coffeyville Community College, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my non-compliance with the recommendation of Coffeyville Community College.
I have read this document and acknowledge that I understand its significance. I further state that I am at least 18 years of age and competent to sign this waiver, or that if I am under 18 years of age, I have the approval of my parent or guardian to sign this waiver as evidenced by their signature on this document.
• I have not been tested _____ • I have been tested and HAVE the trait _____ • I have been tested and DO NOT have the trait _____
Student-Athlete Signature_________________________________________________ Date_________________
Parent/Guardian Signature ______________________________________________ Date_________________
Athletic Training Room Rules
• Only student-athletes who have a completed physical on file
may receive treatment in the athletic training room (ATR).
• All athletes must sign in before receiving treatment.
• Respect everyone in the ATR.
• Inside voices.
• All treatment is at the discretion of Certified AT.
• ATs can refuse treatment.
• NO cell phones/headphones.
• No shoes on table/equipment.
• ATR is not a hangout.
• Proper attire must be worn in ATR.
• Use common sense!
• Any athlete not following rules may be asked to leave.
Athletic Training Room hours:
Monday-Friday: 8am-6pm Weekends: Dependent on game schedule or by appointment only
Hydro Room Rules
• Athletes must sign in in the ATR before receiving treatment.
• Do not touch washer/dryer; these are not for athlete use.
• No open wounds will be allowed in the whirlpool.
• Athlete must supply their own towel.
• Shorts/compressions must be worn in the whirlpool.
• No ice will be added to ice baths without permission of the Head/Assistant Athletic Trainer.
• Clean up after yourself; Ice room area should be wiped down and no water on floor or tables
when athlete is completed with a whirlpool.
• Keep noise level to a minimum.
• Cell phones permitted for texting only. No pictures, videos, or phone calls are to be takin in the
hydro room; CCC is NOT responsible for damages to cell phone/headphones.
• Any athlete not following rules may be asked to leave.
By my signature at the bottom of this document, I acknowledge I have received a copy of the Coffeyville Community College Athletic Training
Room Rules, and I have read and reviewed the rules.
By signing below I understand and agree with rules set by the Athletic Training Staff.
Print Name ________________________________________________
Signature _________________________________________________ Date __________________