2018-2019 HEADS UP CONCUSSION FORM
The Iowa Legislature passed a new law, effective July 1, 2011, regarding students in grades 7 – 12 who participate in
extracurricular interscholastic activities. Please note this important information from Iowa Code Section 280.13C,
Brain Injury Policies:
(1) A child must be immediately removed from participation (practice or competition) if his/her coach or a contest offi cial observes
signs, symptoms, or behaviors consistent with a concussion or brain injury in an extracurricular interscholastic activity.
(2) A child may not participate again until a licensed health care provider trained in the evaluation and management of concussions and
other brain injuries has evaluated him/her and the student has received written clearance from that person to return to participation.
(3) Key defi nitions:
“Licensed health care provider” means a physician, physician assistant, chiropractor, advanced registered nurse
practitioner, nurse, physical therapist, or athletic trainer licensed by a board.
“Extracurricular interscholastic activity” means any extracurricular interscholastic activity, contest, or practice,
including sports, dance, or cheerleading.
What is a concussion?
A concussion is a brain injury. Concussions are caused by a
bump, blow, or jolt to the head or body. Even a “ding,” “getting
your bell rung,” or what seems to be a mild bump or blow to the
head can be serious.
What parents/guardians should do if they think their child has a concussion?
1. OBEY THE NEW LAW.
a. Keep your child out of participation until s/he is cleared to
return by a licensed healthcare provider.
b. Seek medical attention right away.
2. Teach your child that it’s not smart to play with a concussion.
3. Tell all of your child’s coaches and the student’s
school nurse about ANY concussion.
What are the signs and symptoms of a concussion?
You cannot see a concussion. Signs and symptoms of concussion
can show up right after the injury or may not appear or be noticed
until days after the injury. If your teen reports one or more symptoms
of concussion listed below, or if you notice the symptoms yourself,
keep your teen out of play and seek medical attention right away
STUDENTS:If you think you have a concussion:
If you think you have a concussion:
• Tell your coaches & parents – Never ignore a bump or
blow to the head, even if you feel fi ne. Also, tell your coach if
you think one of your teammates might have a concussion.
• Get a medical check-up – A physician or other licensed
health care provider can tell you if you have a concussion, and
when it is OK to return to play.
• Give yourself time to heal – If you have a concussion,
your brain needs time to heal. While your brain is healing,
you are much more likely to have another concussion. It is
important to rest and not return to play until you get the OK
from your health care professional.
IT’S BETTER TO MISS ONE CONTEST THAN THE WHOLE SEASON.
Signs Reported by Students:
• Headache or “pressure” in head
•Nausea or vomiting
•Balance problems or dizziness
•Double or blurry vision
•Sensitivity to light or noise
•Feeling sluggish, hazy, foggy, or groggy
•Concentration or memory problems
•Just not “feeling right” or is “feeling down”
PARENTS:How can you help your child prevent a concussion?
Every sport is different, but there are steps your children can take
to protect themselves from concussion and other injuries.
• Make sure they wear the right protective equipment for their
activity. It should fi t properly, be well maintained, and be worn
consistently and correctly.
• Ensure that they follow their coaches’ rules for safety and the
rules of the sport.
• Encourage them to practice good sportsmanship at all times.
Signs Observed by Parents or Guardians:
• Appears dazed or stunned
•Is confused about assignment or position
•Forgets an instruction
•Is unsure of game, score, or opponent
•Answers questions slowly
•Loses consciousness (even briefl y)
•Shows mood, behavior, or personality changes
•Can’t recall events prior to hit or fall
•Can’t recall events after hit or fall
Information on concussions provided by the Centers for Disease
Control and Prevention.
For more information visit:
IMPORTANT: Students participating in interscholastic athletics, cheerleading and dance; and their parents/guardians; must annually sign the acknowledgement.
School student attends
Osage Middle School
Osage High School
By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
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