Injury and Concussion Reporting Agreement Form

NCAA Athletic Training Form

Injury and Concussion Reporting Agreement Form

NCAA regulations require all varsity student-athletes to be aware of what a concussion is, as well as signs and symptoms of concussion. Please read the below information and sign and date the bottom of the form to be in compliance with NCAA regulations.
What is a concussion?
A concussion is a brain injury that may be caused by a blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick, or field hockey ball.

Signs and Symptoms of a concussion: Headache, nausea, vomiting, balance problems or dizziness, double or blurry vision, sensitivity to light, sensitivity to noise, feeling sluggish, hazy, foggy, or groggy, concentration or memory problems, confusion.

Have you had an orthopedic surgery/injury in the past year (please circle)? Yes No

If yes, what type of surgery/injury?______

If yes, please submit along with this form a note of clearance from your surgeon/orthopedist and all surgical notes to Bates College Sports Medicine.

Have you been diagnosed with a concussion within the last year (please circle)? Yes No

Was this concussion managed and treated by Bates Sports Medicine (please circle)? Yes No

If you have sustained a concussion within the last year that WAS NOT managed by Bates Sports Medicine, please submit along with this form a note of clearance from your diagnosing physician to Bates College Sports Medicine.

How many concussions have you sustained that were diagnosed by a Physician?______If you have had a concussion(s) in the past please provide the dates of concussion(s) and how many days it took for symptoms to clear on the lines below.

Date of 1st concussion:______Number of days you had symptoms:______
Date of 2ndconcussion:______Number of days you had symptoms:______
Date of 3rd concussion:______Number of days you had symptoms:______
Date of 4th concussion:______Number of days you had symptoms:______

I, (please print)______do hereby agree to accept the responsibility for reporting all injuries and illness to the Bates College Medical Staff, including signs and symptoms of concussion.

Signature of Athlete______Date______Sport(s)______Year of Grad______

Request parent/guardian signature if student-athlete is under 18 years old.
Parent/Guardian Signature______Date______
3/17