M:0 - Montachusett Regional Vocational Technical School

MONTACHUSETT REGIONAL VOCATIONAL TECHNICAL SCHOOL DISTRICT
Ashburnham • Ashby •Athol• Barre •Fitchburg• Gardner• Harvard• Holden •Hubbardston• Lunenburg
Petersham • Philipston •Princeton• Royalston • Sterling• Templeton• Westminster• Winchendon
Montachusett Regional Vocational Technical School
Westminster Street
Fitchburg, Massachusetts 01420
(978) 345-9200
Fax: (978) 348-1176
Web Site: http:,. www.montytech.net/050
July 1, 2016
To: Students/Athletes and their Parents/Guardians
Re: State mandated Concussion/Head Injury Packet and Forms
A few years ago the Commonwealth of Massachusetts passed a new regulation on concussions and how they
are handled in interscholastic sports. Pursuant to Massachusetts General Law, Chapter 111, Section 222, "An
Act Relative to Safety Regulations of School Athletic Programs", the Monty Tech High School athletic
department along with our supervising school physician, sports medicine specialist Dr. Stevenson, has refined
and has implemented a policy and protocol to meet the needs of our student/athletes and the state guidelines.
A few of the key points that have been implemented to meet the new regulations are;
•
Before the start of their first sports season, each athlete and their parent/guardian shall receive the
"Parent/Athlete Concussion/Head Injury Education" packet. They shall be responsible to review the
information in this packet. The forms must be completed in full by the student/athlete and their
parent/guardian and returned to the athletic department before the student/athlete will be cleared to
participate in the high school athletic program.
•
Before the start of each sports season, the "Parent/Athlete Concussion/Head Injury Disclosure Form"
must be completed in full by the student/athlete and their parent/guardian. If a parent/guardian has
multiple students, a separate form for each MUST be completed in full and returned to the athletic
department before the student/athlete will be cleared to participate in the high school athletic program.
•
Each student/athlete and their parent/guardian may complete the online course, "CONCUSSION IN
SPORTS, WHAT YOU NEED TO KNOW". This is a free online course that takes about 30 minutes
and you will be able to print a certificate of completion when completed. You should submit a copy of
each certificate along with your completed concussion forms to the athletic department. The website is:
www.nfhslearn.com and the link to the course is located on the page for courses.
We appreciate the cooperation and understanding of each athlete and their parent/guardian as the school works
to implement these regulations. The main goal of the athletic department is the health, safety, and long-term
well being of each and every student/athlete. If you have any questions regarding this issue or the new forms,
please feel free to contact the athletic department's Registered Nurse.
~M
:0 -;~
David Reid
Athletic Director
MONTACHUSETT REGIONAL VOCATIONAL TECHNICAL SCHOOL DISTRICT
Ashburnham • Ashby • Athol • Barre • Fitchburg • Gardner • Harvard • Holden • Hubbardston • Lunenburg
Petersham • Philipsron • Princeron • Royalston • Sterling • Templeton • Westminster• Winchendon
Monrachuseu Regional r·ocarional Techn ical School
Westminster Screer
Fitchburg. Massachuse/ls 01-120
(978) 345-9200
Fax.· (978) 348-1176
Web Sire: hllp: iwww.montycech.net I 050
Parent/Athlete Concussion/Head Injury Education Form
•
Student athletes and their parents or guardians will also be educated on head injuries, concussions, and
second impact syndrome prior to the start of each sports season by way of printed education materials
from the Center for Disease Controls.
•
All athletes with a suspected concussion need to be seen immediately by the athletic department
RN/EMT, EMT, or sports physician and triaged appropriately (monitoring the athlete, notifying parent
or guardian, sending to ED, activating EMS, etc.)
•
Any athlete with a suspected concussion will be removed from participation for the day and will not be
allowed to return until medically cleared by the students' primary care physician or the school physician.
This includes game play, practice, as well as strength & conditioning exercises.
•
Any athlete who experiences a loss of consciousness will be removed from participation for the day and
will not be allowed to return until medically cleared by the students' primary care physician and the
school physician. This includes game play, practice, as well as strength & conditioning exercises.
•
No athlete with continued clinical symptoms will be allowed to return to play at any time
•
The school physician for Monty Tech High School has the final authorization for a students' return to
play after a significant injury and or head injury/concussion. They will review the clearance from the
primary care physician, the history of concussions, the signs and symptoms, and other related medical
information. The athletic department RN/EMT, EMT shall also not accept return to play/practice from
the students' physician if they think it is not in the best interest medically to the student until the school
physician is consulted for approval and consult.
•
If a student athlete or parent/guardian believes that the student has a suspected concussion, they agree to
report it immediately to their coach, covering medical staff, athletic director, or to seek medical attention
if after school hours and the sports event has concluded.
•
More information on concussions and head injuries are to be posted on the Monty Tech athletic web
page.
•
The National Federation of High School Sports offers a free online concussion education video program
on their website. The video ''Concussion in Sports- What you need to know" It is located under the free
course tab under courses at h!tp:1'.2Y~\\,\ ·!llh~l~fiJ!!.CQ)}'l
•
Additional materials and documents to download or view are available at the Centers for Disease
Control and Preventions website at htJp: '_' W\\. v._.~q_c.,g~)~"l~oncu;;sion, ~p_oI1_s.(ipde;,,;J1tn;!
U.S.
DEPARTMENT O F
H EALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL ANO PREVENTION
A Fact Sheet for PARENTS
WHAT IS A CONCUSSIO N?
A concussion is a brain injury. Concussions are caused
by a bump or blow to the head. Even a "ding," "getting
your bell rung," or what seems to be a mild bump or
blow to the head can be serious.
You can't see a concussion. Signs and symptoms of
concussion can show up right after the injury or may
not appear or be noticed until days or weeks after t he
injury. If your child reports any symptoms of concussion,
or if you notice the symptoms yourself, seek medical
attention right away.
WHAT ARE THE SIGNS AND
SYMPTOMS OF A CONCUSSION?
HOW CAN YOU HELP YOUR CHILD
PREVENT A CONCUSSION?
Every sport is different, but t here are steps your children
can take to protect t hemselves from concussion.
Ensure that they fo llow their coach's rules for
safety and the rules of the sport.
Encourage them to practice good sportsmanship
at al I times.
Make sure they wear the right protective equipment
for their activity (such as helmets, padding, shin
guards, and eye and mouth guards). Protective
equipment should fit properly, be well maintained,
and be worn consistently and correctly.
Learn the signs and symptoms of a concussion.
Signs Observed by Parents or Guardians
If your child has experienced a bump or blow to the
head during a game or practice, look for any of the
following signs and symptoms of a concussion:
Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
• Is unsure of game, score, or opponent
• Moves clumsily
• Answers questions slowly
Loses consciousness (even briefly)
Shows behavior or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fal I
Symptoms Reported by Athlete
Headache or "pressure" in head
Nausea or 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
Does not "feel ri ght"
WHAT SHOULD YOU DO IF YOU THINK
YOUR CHILD HAS A CONCUSSION?
1. Seek medical attention right away. A health
care professional wil I be able to decide how serious
the concussion is and when it is safe for your child
to return to sports.
2. Keep your child out of play. Concussions take
time to heal. Don't let your child return to play
until a health care professional says it's 01<.
Children who return to play too soon-while the
brain is still healing-risk a greater chance of
having a second concussion. Second or later
concussions can be very serious. They can cause
permanent brain damage, affecting your child for
a lifetime.
3. Tell your child's coach about any recent
concussion. Coaches should know if your child
had a recent concussion in ANY sport. Your
child's coach may not know about a concussion
your child received in another sport or activity
un less you tell the coach.
DEPARTA.MENTO DE SALUD 'f
SERVICIOS
HuMANOS 0£ LOS ESTA.DOS UNIDO S
CENTROS PARA EL CONTROL Y LA P R EVENC l 6N O E ENFERMEDA.DE S
Hoja I nfo rm ativa para los PADRES
Una conmocion cerebral es una lesion ~n el cerebra, causada
,COMO AYUDAR A SU HIJO A PREVENIR UNA
CONMOCION CEREBRAL?
por un golpe en la cabeza o una sacudida. Incluso una pequeiia
Aunque todo deporte es diferente, hay medidas que puede tomar
conmocion o lo que parece ser un golpe o sacudida leve puede
para protegerse.
;.QUE ES LA CONMOCION CEREBRAL?
ser serio.
Haga que siga las reg las impartidas por el entr enador y las
La conmocion cerebral no puede verse. Los signos y sintomas de
lnvitel o a mantener el espiritu deportivo en todo momenta.
reg las del depor te que practica.
una conmocion pueden aparecer inmediatamente despues de la
Haga que su hijo use el equipo protector adecuado segun la
lesion o puede que no aparezcan, o se hagan visibles algunos dias
actividad que realiza (como casco, almohadillas protectoras,
o meses despues de haber sufrido la lesion. Si su hijo t iene los
canilleras o protector dental). El equ ipo de protecci6n debe
signos de una conmocion cerebral o si usted nota algun sfntorna,
ajustarse bien, debe hacersele el mantenimiento adecuado, y
busque atencion medica de inmediato.
el jugador debe usarlo correctamente y en todo momenta.
;.CUALES SON LOS SIGNOS Y SiNTOMAS DE LA
CONMOCION CEREBRAL?
Signos que notan los padres y los tutores
Si su hijo ha sufrido un golpe en la cabeza o una sacudida
durante un juego o una prcictica, obseNelo para determinar si
tiene alguno de los siguientes signos y sfntomas de una
conmocicin cerebral:
Luce aturdido o fuera de control
Se confunde con la actividad asignada
Olvida las jugadas
No se muestra seguro del juego, la puntuaci6n ni de sus
Aprenda a identificar los signos y sfntomas de la conmoci6n.
,QUE DEBE HACER SI CREE QUE SU HIJO HA SUFRIDO
UNA CONMOCION CEREBRAL?
1. Busque atenci6n medica de inmediato. Un profesional
de la salud podra determinar la seriedad de la conmoci6n
cerebral que ha sufrido el niiio y cuando podra regresar al
juego sin riesgo alguno.
2. No permita que su hijo siga jugando.
Las conmociones
cerebrales necesitan de un ciert o tiempo para curarse. No
adversarios
permita que su hijo regrese al juego hasta que un profesional
Se mueve con torpeza
Responde con lentitud
Pierde el conocimiento (asi sea momentaneamente)
regresan al juego antes de lo debido - mientras el cerebra
Muestra cambios de conducta ode personalidad
No puede recordar lo ocurrido antes de un lanzamiento
sufrir otra conmoci6n. Las conmociones cerebrales siguientes
o un caida
No puede recordar lo ocurrido despues de un lanzamiento
permanente que afectaran al niiio de por vida.
o un caida
Sintomas que reporta el atleta
Dolor o "presion" en la cabeza
Nauseas o vomitos
Problemas de equilibria, mareo
Vision doble o borrosa
Sensibilidad a la luz y al ruido
Se siente debil, confuso, aturdido o grogui
Problemas de concentracion o memoria
Confusion
Nose "siente bien"
de la salud le haya dicho que puede hacerlo. Los niiios que
esta en proceso de curacion - corren un mayor riesgo de
pueden ser muy serias. Pueden causar daiio cerebral
3. Informe al entrenador del nino sobre cualquier
conmoci6n cerebral que el nino haya sufrido
recientemente. Los entrenadores deben saber si el
niiio
ha sufrido una conmocion recientemente en CUALQU I ER
deporte. EI entrenador no necesariamente sabra si el niiio
ha tenido una conmoci6n en otro deporte o actividad a
menos que usted se lo diga.
U . S. DEPARTMENT OF HEALTH AND
HUMAN
SERVICES
CENTERS FCR DISEASE CONTROL ANO PREVENTION
A Fact Sheet for ATHLETES
WHAT IS A CONCUSSION?
A concussion is a brain injury that:
· ls caused by a bump or blow to the head
· Can change the way your brain normally works
• Can occur during practices or games in
any sport
, Can happen even if you haven't been
knocked out
• Can be serious even if you've j ust been "dinged"
WHAT ARE THE SYMPTOMS OF
A CONCUSSION?
• Headache or "pressure" in head
~
Nausea or vomiting
, Balance problems or dizziness
• Double or blu rry vision
, Bothered by light
' Bothered by noise
• Feeling sluggish, hazy, foggy, or groggy
• Difficulty paying attention
, Memory problems
Confusion
, Does not "feel right"
Get a medical chec l< up. A doctor or health care
professional can tel I you if you have a concussion
and when you are 01< to return to play.
, Give yourself time to get better. If you have
had a concussion, your brain needs t ime to heal .
While your brain is still heal ing, you are much
more likely to have a second concussion. Second
or later concuss ions can cause damage to your
brain. It is important to rest until you get
approval fro m a doctor or health care
pr ofessional to return to play.
HOW CAN I PREVENT A CONCUSSION?
Every sport is different, but there are steps you
can take to protect yourself.
· Follow your coach's rules for safety and the
rul es of the sport.
Practice good sportsmanship at all t imes.
• Use the proper sports equipment, including
personal protective equipment (such as helmets,
padd ing, shin g\Jard s, and eye and mouth
guards) . In order for equipment to protect you,
it must be :
WHAT SHOULD I DO IF I THINK
I HAVE A CONCUSSION?
. Tell your coaches and your parents. Never
ignore a bump or blow to the head even if you
.., The rig ht equipment for the game, position,
or activity
Worn correctly and fit well
Used every time you play
feel fine. Also, tell your coach if one of your
teammates might have a concussion.
It's better to miss one game than the whole season.
For rno•e 1rformation and to order additional materials free-of-charge visit:
For more detailed information on concussion and traumatic brain inJuiy. visit:
www.cdc.gov/Concussion In YouthSports
www.cdc.gov/ concussion
DEPARTA MENTO OE SAL..UD Y
SERV I C I OS
HUMANOS OE
LOS
ESTAOOS
UNIOOS
CENTROS PARA EL CONTROL Y LA PREVEii.,ct6N OE ENF E RMEOAOES
Hoja Informativa para los ATLETAS
;.QUE ES LA CONMOCION CEREBRAL?
sientas bien. Tambien dile al entrenador si crees que uno
La conmoci6 n cerebral es una lesion del cerebra que:
de tus compafieros de equipo sufrio una conmoci6n.
Es causada por un golpe en la cabeza o una sacudida
Puede cambiar el funcionamiento normal del cerebra
Puede ocurrir en cualquier deporte durante las practicas
Ve al medico para que te examine.
Un medico u otro
profesional de la salud podra decirte si sufriste una conmocion
cerebral y cuando estaras Jisto para volver a jugar.
de entrenamie nto o durante un juego
Puede ocurrir aun cuando no se haya perdido el
Tomate el tiempo suficiente para curarte. Si sufriste
conocimiento
una conmoci6n cerebral, tu cerebra necesitara tiempo
Puede ser seria aun si se piensa que solo se trata de un
para sanar. Es mas probable que sufras una segunda
golpe leve
conmocion mientras tu cerebra este en proceso de
curac ion. Las segundas conmociones y cualquier
;.CUALES SON LOS SiNTOMAS DE LA CONMOCION
CEREBRAL?
conmocion adicional pueden causar dafios al cerebra.
Por eso es importante que descanses hasta que un
Dolor o "presi6n" en la cabeza
medico u otro profesional de la salud te permitan
Nauseas (sentir que quieres vomitarl
regresar al campo de juego.
Problemas de equilibria, rnareo
,COMO PUEDO PREVENIR UNA CONMOCIGN
CEREBRAL?
, Vision doble o borrosa
, Molestia causada por la luz
Aunque todo deporte es diferente, hay medidas que puedes
Molestia causada por el ruido
Sentirse debilitado, confuse, aturdido o grogui
tomar para protegerte.
Sigue las reglas de seguridad del entrenador y las reglas
Dificultad para concentrarse
del deporte que practicas.
Problemas de memoria
Manten el espfritu deportivo en todo memento.
Confusion
Utiliza los implementos deportivos adecuados, incluido
• No "sentirse bien"
el equipo de protecci6n personal (coma casco,
,GUE DEBO HACER SI CREO QUE HE SUFRIDO UNA
CONMOCION CEREBRAL?
Dile a tus entrenadores ya tus padres.
Nunca ignores
un go lpe en la cabeza o una sacudida aun cuando te
almohadil las protectoras, can ii Ieras, gafas y protector
dental l . Para que este equipo te proteja, debe:
Ser adecuado para el deporte que practicas, tu
posici6n en el juego y tipo de actividad
Usarse correctamente y ajustarse bien a tu cuerpo
Usarse en todo momenta durante el juego
Es preferible perderse un juego que toda la temporada.
Pa·a :::=·=· - .
·- · -aci6n o sot•c;tar mas materiales de forma gratuita visite:
www.cdc.gov/ConcussioninYouthSports
Para obtener · nformacion mas detallada sobre la conmocion cerebral 'f la
lesion cereoral , raumatica, vis1te: www.cdc.gov/concussion
MONTACHUSETT REGIONAL VOCATIONAL TECHNICAL SCHOOL DISTRICT
Ashburnham • Ashby • Athol• Barre • Fitchburg• Gardner• Harvard• Holden • Hubbardston • Lunenburg
Petersham• Philipston • Princeton • Royalston• Sterling • Templeton• Westminster• Winchendon
Montachuseu Regional 1·ocaciona/ Technical School
Westminster Scree,
Fitchburg. Massachusetls () I ./20
(978) 3./5-920()
Fax: (978) 3./8-1176
Web Site: hap: .'·www.montycech.net I ()50
Parent/Athlete Concussion/Head Injury Education Form
Athlete/participant name (printed)
YOG
Sport
*I attest that I have received, reviewed, and agree to follow the Parent/Athlete Concussion/Head Injury
Education Form and the "Heads up Concussion in High School Sports, A fact sheet for athletes" and "Heads up:
Preventing Concussion" both from the Centers of Disease Control and Prevention. If at any time I seek further
information on this topic or clarification I will seek out the coach, school medical staff, or athletic director.
Athlete/participant signature
Date
Parent/Guardian name (printed)
*I attest that I have received, reviewed, and agree to follow the Parent/Athlete Concussion/Head Injury
Education Form and the "Heads up Concussion in High School Sports, A fact sheet for parents" and "Heads up:
Preventing Concussion" both from the Centers of Disease Control and Prevention. If at any time I see further
information on this topic of clarification I will seek out the coach, school medical staff, or athletic director. If a
parent/guardian wishes to speak with the supervising school physician about this topic and a possible
concussion/head injury they shall inform the athletic director or medical coverage staff and arrangements will
be made you to speak with them.
Parent/Guardian signature
Date
MONTACHUSETT REGIONAL VOCATIONAL TECHNICAL SCH OOL DISTRICT
........ .........
Ashburnham •Ashby• Athol • Barre •Fitchburg• Gardner• Harvard• Holden• Hubbardston • Lunenburg
Petersham • Philipston • Princeton • Royalston •Sterling • Templeton • Westminster • Winchendon
~
~
Montachuseu Regional I ·ocational Technical School
tn50 Westminster Streer
Fitchburg, Massachusetts O1./20
(978) 3./5-92()(/
Fax: (978) 3-18-1176
Web Site: http: , ·www.montytech.net
Parent/Athlete Concussion/Head Injury Disclosure Form
Pursuant to Massachusetts General Law, Chapter 111 , Section 222, "An Act Relative to Safety Regulations of
School Athletic Programs", participants of interscholastic athletic programs and their parents, prior to each
season, must disclose any information relative to any head injury/concussion history . This information must be
shared with the athlete's coach and a copy will be kept on file with the Athletic Director.
Have you ever exhibited signs, symptoms, or behaviors consistent with a concussion/head injury (such as loss of
consciousness, headache, dizziness, confusion, or balance problems) during a sporting competition or practice at
any level?
- - - YES
- --
NO
Have you ever been diagnosed with a concussion, possible concussion, or head injury by a medical professional?
- - - YES
- --
NO
If you answered yes to either of the above questions. please list and explain each individual circumstance
describing the signs and symptoms, treatments and the date of each incident.
Sport_ __ _ _ _ _ _ _ __ _
Do you currently have, or ever you ever had athletic participation restrictions in relation to being diagnosed with a
concussion?
- --
YES
-
--
NO
I attest that the above information is accurate to the best of my knowledge, MUST be signed by both student and parent/guardian.
Parent/Guardian N ame (Print)
Student/Athlete Name (Print)
Parent/Guardian Signature
Student/Athlete Signature
Date
Date