Concussion Injury Statement

This form outlines concussion education and management expectations for student-athletes at Vincennes University.
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Concussion Injury Statement
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Student Athlete Information

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Student-Athlete Cell Number
Student-Athletes Email

Acknowledgments

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Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment
Please read carefully & understand before you complete the acknowledgment (required)
Concussion Definition
A concussion is defined as a generally short-lived impairment of neurological function brought on by a traumatic force applied to the head or body. Symptoms are usually rapid in onset, but of short duration and generally resolve spontaneously. It is usually a functional disturbance and not a structural one. Loss of consciousness may or may not be involved. 
 
Concussion Management Policy
The Vincennes University Sports Medicine staff recognizes and acknowledges that concussions or traumatic brain injuries (TBI) need immediate attention. As a recognized leader in the space, the National Collegiate Athletic Association (NCAA) has developed a consistent, association-wide approach to Concussion Management. It is the responsibility of all student-athletes to report injuries and illnesses to their Athletic Trainer. This includes, but is not limited to, signs and symptoms related to concussions. 
Identifying a Concussion

The Vincennes University Sports Medicine staff will determine if a concussion has occurred. We follow American Academy of Neurology guidelines for assessment, recognizing that each concussion and student-athlete is unique, requiring an individualized treatment plan.

Common signs and symptoms of a concussion include, but are not limited to:

  • Headache
  • Nausea
  • Balance problems
  • Dizziness
  • Double vision (diplopia)
  • Confusion
  • Light sensitivity (photophobia)
  • Difficulty sleeping
  • Noise sensitivity (misophonia)
  • Blurred vision
  • Sluggish or groggy feelings
  • Memory problems
  • Difficulty concentrating
Responsibility to Report Injuries
I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer/athletic healthcare provider and/or team physician
Concussion Baseline Testing
As an incoming Vincennes University student-athlete, I will participate in concussion baseline testing.
Concussion is Brain Injury
A concussion is a brain injury, which I am responsible for reporting to my athletic trainer/athletic health care provider or team physician.
Concussion Effects & Reporting
A concussion can affect my ability to perform everyday activities, affect reaction time, balance, sleep, and classroom performance.
Invisible Symptoms of Concussion
You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after injury.
Reporting Teammate's Concussion  
If I suspect a teammate has a concussion, I am responsible for reporting the injury to the athletic trainer/athletic health care provider or team physician.
No Return to Play with Symptoms  
I will not return to practice or play in a contest if I have received a blow to the head or body that results in concussion related symptoms. 
Brain Healing Time Post-Concussion
Following a concussion, the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. 
Repeat Concussion Risks
In rare cases, repeat concussion can cause permanent brain damage, and even death.
Attestation
I certify, under penalty of perjury of the laws of the State of Indiana, that I have read the contents and warning of this acknowledgement; that I fully understand this acknowledgment; that I am in agreement with the terms of this acknowledgment; that I am signing this acknowledgement voluntarily, under no compulsion; that I have had an opportunity to ask questions and seek advice regarding this acknowledgement; that I am age 18 or over or, if not, that my parents/guardians hereby make these promises on my behalf; and that I choose to participate (or to permit my child or ward to participate) in the Vincennes University activity listed below of my own accord.
Acknowledgment & Consent
Clicking Submit signifies that you have thoroughly read and fully understand all the information presented in this form. This consent, waiver, indemnity and release is binding on me, my heirs, executors, administrators and assigns.This action is the equivalent of providing your handwritten signature and the current date.

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