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Concussion Information Form

Concussion Information Sheet

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A concussion is a brain injury and all brain injuries are serious.  They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head.  They can range from mild to severe and can disrupt the way the brain normally works.  Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly.  In other words, even a “ding” or a bump on the head can be serious.  You can’t see a concussion and most sports concussions occur without loss of consciousness.  Signs and symptoms of concussions may show up right after the injury or can take hours or days to fully appear.  If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.


Symptoms may include one or more of the following:

·       Headaches

·       “Pressure in head”

·       Nausea or vomiting

·       Neck pain

·       Balance problems or dizziness

·       Blurred, double, or fuzzy vision

·       Sensitivity to light or noise

·       Feeling sluggish or slowed down

·       Feeling foggy or groggy

·       Drowsiness

·       Change in sleep patterns

·       Amnesia

·       “Don’t feel right”

·       Fatigue or low energy

·       Sadness

·       Nervousness or anxiety

·       Irritability

·       More emotional

·       Confusion

·       Concentration or memory problems (forgetting game plays)

·       Repeating the same question/comment

Signs observed by teammates, parents and coaches include:

·       Appears dazed

·       Vacant facial expression

·       Confused about assignment

·       Forgets plays

·       Is unsure of game, score, or opponent

·       Moves clumsily or displays in coordination

·       Answers questions slowly

·       Slurred speech

·       Shows behavior or personality changes

·       Can’t recall events prior to hit

·       Can’t recall events after hit

·       Seizures or convulsions

·       Any change in typical behavior or personality

·       Loses consciousness


Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 7/1/2012 Reviewed 4/24/2013


Concussion Information Sheet


What can happen if my child keeps on playing with a concussion or returns to school?

Athletes with the signs and symptoms of concussion should be removed from play immediately.  Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury.  There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one.  This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences.  It is well known that adolescent or teenage athletes will often fail to report symptoms of injuries.  Concussions are no different.  As a result, education of administrators, coaches, parents and students is the key to student-athlete’s safety.


If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately.  No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance.  Close observation of the athlete should continue for several hours.  The Return-to-Play Policy of the IESA and IHSA requires athletes to provide their school with written clearance from either a physician licensed to practice medicine in all its branches or a certified athletic trainer working in conjunction with a physician licensed to practice medicine in all its branches prior to returning to play or practice following a concussion or after being removed from an interscholastic contest due to a possible head injury or concussion and not cleared to return to that same contest. In accordance with state law, all schools are required to follow this policy.

You should also inform your child’s coach if you think that your child may have a concussion.  Remember it’s better to miss one game than miss the whole season.  And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to:


Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 7/1/2012 Reviewed 4/24/2013




Concussion Information Sheet

Student /Parent Consent and Acknowledgements

By signing this form, we acknowledge we have been provided information regarding concussions.



   Student Name (Print): __________________________________________              Grade: _______


     Student Signature: ____________________________________________          Date: ________


Parent or Legal Guardian

   Name (Print): _________________________________________________


     Signature: ___________________________________________________       Date: ________


   Relationship to Student: _________________________________________



Each year IESA member schools are required to keep a signed Acknowledgement and Consent form and a current Pre-participation Examination on file for all student athletes.