MORRISTOWN HIGH SCHOOL
ImPACT Consent/Procedure Form
The Morris School District has implemented an innovative program for our student-athletes. This program assists our team physicians/athletic trainers in evaluating and treating head injuries (e.g. concussion). In order to better manage concussions sustained by our student-athletes, we use a software tool called ImPACT (Immediate Post Concussion Assessment and Cognitive Testing). ImPACT is a computerized exam utilized in many professional, collegiate, and high school sports programs across the country to successfully diagnose and manage concussions. If a student-athlete is believed to have suffered a head injury during competition, ImPACT is used to help determine the severity of head injury and when the injury has fully healed.
The computerized exam is given to student-athletes before beginning sport practice or competition. This non-invasive test is set up in a “video game” type format and takes about 15-20 minutes to complete. It is simple and, actually, many student-athletes enjoy the challenge of taking the test. The ImPACT testing tracks information such as memory, reaction time, speed and concentration. It, however, is not an IQ test.
In an effort to reduce confusion and to increase our efficiency in administering the test we have developed “At Home” instructions (located on the next page) for each student-athlete to complete prior to RECEIVING YOUR BLUE CARD.
If a concussion is suspected, the student-athlete will be required to retake the test either a doctor's office or here at the High School with our Athletic Trainers. Both preseason and post-injury test data is given to a local doctor, neuropsychologist or neurophysiologist. The information gathered can also be shared with your family doctor. This test data will enable these health professionals to determine when return-to-play is appropriate and safe for the injured student-athlete. If an injury of this nature occurs to your child, you will be promptly contacted with all the details.
I wish to stress that the ImPACT testing procedures are non-invasive and the pose no risk to your student-athlete. If you have any further questions regarding this program, please feel free to contact the Head Athletic Trainer. Participation in this program can be revoked and/or modified in writing at any time by the student-athlete or his/her parents or guardians.
By signing below, you are allowing your student-athlete to participate in the ImPACT program.
I understand that this is a non-invasive test and that all results will be kept confidential and abide by all Family Education Rights and Privacy Act (FERPA) Guidelines. I understand that there will be no charge for this testing.
I give my permission for my child, ______(print), whose date of birth is, ______, to be initially tested using the ImPACT Concussion Assessment Program. I am confirming that my child took the ImPact test at home in a quiet setting in accordance with ImPact testing protocols.
Sport: ______Student Signature: ______
Student’s Home Address: ______
Parent/Guardian Name: ______(Print)
Parent/Guardian Signature: ______Date: ______
Parent/Guardian Phone Numbers (H): ______(C): ______(W): ______
Physician’s to whom results may be released to: (Please Print)
Name Of Doctor/ Phone#: ______
*****Please print the confirmation once the test has been completed and return to MHS Health Office*****
Revised 9/15