Dear Student-Athlete and Parents:
Welcome to the University of South Florida and its Intercollegiate Athletics Program. As a student-athlete, it is
necessary for us to gather pertinent medical information in order to determine if you are medically eligible to
participate in intercollegiate athletics.
Enclosed, you will find a packet of forms that require your attention. When completing these forms, please
answer all questions to the best of your knowledge. Below is a list of forms followed by a brief description. If
you have any questions, please feel free to contact one of the athletic training staff members via the numbers
listed below.
As a student-athlete, you will be required to participate in a comprehensive physical exam once every year given
by the University of South Florida Sports Medicine staff.
ü MEDICAL HISTORY: This will inform us of any previous medical problems and hopefully prevent any further problems from occurring.
ü
ü HEALTH INSURANCE/PERSONAL INFORMATION FORM: A photocopy of both sides of all insurance cards (medical, dental, vision, prescription) must be attached to the completed form. This form also provides contact information in the event of an emergency.
ü BIOLOGICAL TESTING CONSENT FORM: By signing this form, you are indicating your understanding of the program and your agreement to be screened for banned substances. Screening takes place randomly throughout the year for all athletes. Participation in athletics is contingent upon adherence to the program and the signing of the consent form.
ü INFORMATION RELEASE AUTHORIZATION FORM: This forms gives the athletic training staff permission to release your medical history to team physicians, coaches, athletic staff members, student athletic trainers, parent(s)/ guardian(s), teammates, and professional scouts. These forms are required to be completed only once during your athletic career at USF.
ü NCAA AND USF POLICY REGARDING LIABILITY: This form allows us to provide emergency medical care to you and terminate participation for health reasons at any time.
ü NOTICE OF PATIENT INFORMATION PRIVACY PRACTICES: This form is informative and may be kept for your records. The notice explains your rights as a patient and how the USF Sports Medicine staff may use your medical information. Please return the acknowledgement page.
ü SICKLE CELL TESTING: As of 2010, the NCAA mandates that every athlete be tested for sickle cell trait. Before you are allowed to try out, you must either have the results of your test or sign the waiver that will be provided when this packet is turned in.
ü CONCUSSION MANAGEMENT PROTOCOL: this document states that you have where provided and read the information provide on the NCAA and National Athletic Trainers Association recommendations on Concussion Management.
If you have any questions please feel free to contact one of us at in the Athletic Training room at (813) 974-0514.
Welcome to the University of South Florida and participation in NCAA Athletics. It is our goal to provide you the student athletes with the best possible athletic health care. To achieve this goal, we will need your assistance with a variety of matters.
If your insurance does NOT have current medical insurance that covers NCAA Athletics, it is highly advisable that you obtain some form of coverage. We currently work with an insurance agency that offers primary athletic insurance for student athletes. Please contact us if you have questions or would like more information.
If you have a managed care insurance policy (HMO, POS) that requires the use of a Primary Care Physician (PCP), we strongly urge you to change your student’s PCP to one of our USF team physicians. Most insurance companies will allow you to change the PCP of one family member without affecting the PCP for any other family members covered by the plan. Changing your son/daughter’s PCP will benefit you and your family in many ways:
1. Allow your son/daughter easy access to his/her PCP, as our USF team physicians are located on campus , less than a mile from our athletic facilities
2. Expedite your son/daughter’s medical care by removing the need for a prior approval from another PCP before seeing our team physicians
3. Cut down on medical costs to you in the event a non-athletic injury does occur; non-athletic injuries and illnesses are not covered by the USF policy and all costs will be the responsibility of the student athlete
4. Allow for better communication regarding injuries between all parties involved (including athletic trainers, team physicians, student athletes and parents)
To change the primary care physician for your son/daughter, simply contact your insurance carrier at the phone number listed on your insurance card. The insurance company will ask you for the name of the physician of which you would like to switch; our head team physician’s name and address is listed below for your convenience. Please notify the Sports Medicine Department at (813) 974-0514 once the change of PCP has been completed.
Dr. Eric Coris
12901 Bruce B Downs Boulevard USF Medical Center
Tampa, FL 33612 (813) 974-2201
The USF Athletic Department athletic accident policy provides insurance for a student athlete’s injuries incurred while participating in a USF sanctioned practice or game. The USF athletic accident insurance policy is ‘excess’ or ‘secondary’ to any other collectible insurance benefits. Any claim for benefits must be first filed with the student athlete’s primary insurance company. The USF policy will cover remaining medical expenses at the reasonable and customary level.
This is where we will need your assistance. It is imperative that ALL bills, Explanation of Benefits Statements or other claim correspondence is forwarded to Janet Britton-Rodgers and the athletic training team. In order for USF to expedite the payment process, we need all information that is sent to your son/daughter or you directly. This will allow us to process the athletic claims in a timely fashion and make sure all primary insurance is being utilized. This will also ensure your account is not sent to collections for lack of payment.
If you have any questions regarding athletic insurance or these procedures, please feel free to contact us at your convenience. We very much appreciate your attention to this matter and look forward to having your son/daughter participate in the University of South Florida Athletics.
Go Bulls!
Janet Britton-Rodgers Insurance Supervisor
MEDICAL HISTORY
Family History
Does anyone in your family have a history of medical problems? Y / N
If yes, explain: __________________________________________________________________ Mother: ________________________________________________________ Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Father: _________________________________________________________ Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Brother(s): ______________________________________________________Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Sister(s): ________________________________________________________Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Has anyone in your family ever been diagnosed with:
Y / N Sudden unexplained death Relationship: ____________________________ Explain: __________________________________________________________ Y / N Alcohol/Substance Abuse Relationship: ____________________________ Explain: __________________________________________________________ Y / N Asthma Relationship: ____________________________ Explain: __________________________________________________________ Y / N Cancer Relationship: ____________________________ Explain: __________________________________________________________ Y / N Diabetes Relationship: ____________________________ Explain: __________________________________________________________ Y / N Heart Disease (of any kind) Relationship: ____________________________ Explain: __________________________________________________________ Y / N High Blood Pressure Relationship: ____________________________ Explain: __________________________________________________________ Y / N Marfan Syndrome Relationship: ____________________________ Explain: __________________________________________________________ Y / N Migraines/Severe Headaches Relationship: ____________________________ Explain: __________________________________________________________ Y / N Osteoporosis/Bone Disorder Relationship: ____________________________ Explain: __________________________________________________________ Y / N Seizures/Epilepsy Relationship: ____________________________ Explain: __________________________________________________________ Y / N Sickle Cell Disease/Trait Relationship: ____________________________ Explain: __________________________________________________________
Name __________________________________ Date ___________________
Date of Birth ____ / ____ / ____
Sport _______________________________
Current Medical Conditions:
Y / N Are you currently under medical supervision for an injury/illness?
If yes, explain: __________________________________________________________________ Y / N Do you have a current ongoing or chronic illness?
If yes, explain: __________________________________________________________________
Surgery/Hospitalization:
Y / N Have you ever had surgery?
Date: ________________ Surgery: ______________________________ Date: ________________ Surgery: ______________________________ Date: ________________ Surgery: ______________________________ Y / N Have you ever been hospitalized for a reason other than surgery?
Date: ________________ Reason: _______________________________ Date: ________________ Reason: _______________________________ Y / N Have you ever been advised to have a surgery not yet performed?
If yes, explain: _________________________________________________________________
Medications:
Y / N Do you regularly use any prescription medication?
If yes, explain: _________________________________________________________________ Y / N Do you regularly use non-prescription medication?
If yes, explain: _________________________________________________________________ Y / N Do you regularly take any dietary supplements?
If yes, explain: _________________________________________________________________
Y / N Have you ever taken supplements or vitamins to help you gain/lose weight in order to improve your performance? If yes, explain: _________________________________________________________________
Alleriges:
Are you allergic to any of the following: Y / N Aspirin
Y / N Food (specify) __________________________ Y / N Dust/pollen
Y / N Insect stings (specify) _____________________ Y / N Penicillin
Y / N Sulfa Drugs Y / N Novocaine
Illnesses:
Have you had any of the following illnesses:
Y / N Chicken Pox Date: _______________ Y / N Diabetes Date: _______________ Y / N Hepatitis Date: _______________ Y / N Measles Date: _______________ Y / N Mononucleosis “Mono” Date: _______________ Y / N Pneumonia Date: _______________ Have you ever had any of the following:
Y / N Anemia
Y / N Sickle Cell Disease/ Sickle Cell Trait Y / N Eye injury or other eye problem Y / N Hearing loss
Y / N Severe tooth or gum trouble
Y / N Severe skin problems (rash, acne, burns, etc.) Do you have loss or seriously impaired function of any paired organ?
Y / N Ear Y / N Eye Y / N Kidney Y / N Ovary Y / N Testicle Y / N Lung Cardiovascular System:
Y / N Do you get more fatigued (tired) during exercise, or get fatigued earlier during exercise than your teammates? Y / N Do you become more short of breath during exercise than your teammates?
Y / N Have you ever fainted or passed out during or after exercise? Y / N Have you ever had chest pains during or after exercise?
Y / N Have you ever been told that you have high blood pressure (hypertension)? Y / N Have you ever been told that you have a heart murmur?
Y / N Have you ever been told that you had high cholesterol (hyperlipidemia)?
Y / N Has a physician ever ordered heart testing (for example: EKG, Echo, stress test, holter monitor)? If yes, please explain:____________________________________________________________
Y / N Have you ever been diagnosed with any type of heart disease (hypertrophic cardiomyopathy, coronary artery abnormality, heart infection, heart valve disease, Marfan’s Syndrome, etc)?
If yes, please specify: ____________________________________________________________ Y / N Have you ever been told that you need to take medication before seeing a dentist?
Y / N Have you ever had a racing heart or skipped heart beats?
Y / N Has anyone in your family died of heart problems or sudden death before the age of 50?
If you answered yes to any of the above questions, please explain: _________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
Respiratory System:
Y / N Do you cough, wheeze, have difficulty breathing, or get short of breath during exercise?
If yes, how often? _______________________________________________________________ Y / N Have you ever been diagnosed with asthma?
Y / N If so, is your asthma well controlled?
Please check one: I have symptoms from my asthma: daily_____ More than twice per week_____ Less than twice per week _____ Hardly ever _____
Y / N Do you use an inhaler?
If yes, what kind? _______________________________________________________________ Y / N Do you have seasonal allergies that require medical treatment or medication?
Neurological System:
Y / N Have you ever had a head injury or a concussion?
Date: ___________________ Explain: _________________________________ If so, how many concussions? __________________________________________ Y / N Have you ever been knocked out, unconscious, or lost your memory?
Date: ___________________ Explain: _________________________________ Y / N Have you ever had a seizure?
Date: ___________________ Explain: _________________________________ Y / N Have you ever had a stinger, burner, or pinched nerve?
Date: ___________________ Explain: _________________________________
Heat Illnesses:
Y / N Have you ever had heat stroke or heat exhaustion?
If so, please explain: _____________________________________________________________ Y / N Have you ever had muscle cramps caused be the heat? How often? _______________________ Y / N Have you ever been dizzy or fainted in the heat? How often? ____________________________ Y / N Have you ever been confused in the heat? How often? _________________________________ Y / N Have you ever been hospitalized for a heat related condition?
Nutrition:
Y / N Do you want to weigh more or less than you currently do?
Y / N Do you frequently lose weight or gain weight to meet the requirements of your sport? Y / N Would you be interested in seeing a sports nutritionist?
Women Only:
What was the date of your last menstrual period? ____________________________________________ When was your first menstrual period? ____________________________________________________ How many periods have you had in the last year? ____________________________________________ What was the longest time between periods in the last year? ____________________________________ My periods are now (circle one):
Regular ⇒ every 24-35 days Irregular ⇒ every 36 days or more
Absent ⇒ no periods for the past three months Y / N Are you currently taking a form of birth control?
If yes, what kind? _______________________________________________________________ Y / N Is there a history of osteoporosis in your family?
Y / N Is there a history of repeated fracture in anyone in your family? Y / N Have you had repeated fractures or repeated stress fractures before?
Protective Devices:
Y / N Do you wear contacts? Y / N Do you wear glasses?
Y / N Do you wear orthotics in your shoes?
Y / N Do you wear any corrective braces or supports?
If yes, what? ___________________________________________________________________
Musculoskeletal System:
Have you ever injured any of the following extremities that caused you to miss a week or more participation in your sport?
Y / N Hip Left / Right Date: __________ Explain: ______________________ Y / N Groin Left / Right Date: __________ Explain: ______________________ Y / N Thigh Left / Right Date: __________ Explain: ______________________ Y / N Knee Left / Right Date: __________ Explain: ______________________ Y / N Shin/Calf Left / Right Date: __________ Explain: ______________________ Y / N Ankle Left / Right Date: __________ Explain: ______________________ Y / N Foot/Toes Left / Right Date: __________ Explain: ______________________ Y / N Skull/Face Left / Right Date: __________ Explain: ______________________ Y / N Teeth/Jaw Left / Right Date: __________ Explain: ______________________ Y / N Neck Left / Right Date: __________ Explain: ______________________ Y / N Back Left / Right Date: __________ Explain: ______________________ Y / N Shoulder Left / Right Date: __________ Explain: ______________________ Y / N Upper Arm Left / Right Date: __________ Explain: ______________________ Y / N Elbow Left / Right Date: __________ Explain: ______________________ Y / N Forearm Left / Right Date: __________ Explain: ______________________ Y / N Wrist Left / Right Date: __________ Explain: ______________________ Y / N Hand/Fingers Left / Right Date: __________ Explain: ______________________
Other Medical Conditions:
Y / N Have you ever been told, for any reason, that you should not participate in sports?
If yes, explain: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Y / N Do you know of, or believe, there is any reason that should prevent you from participating in intercollegiate athletics?
If yes, explain: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
I certify that the answers to the preceding questions are correct and true to the best of my knowledge. I
understand that passing the physical exam does not necessarily mean that I am physically qualified to
engage in intercollegiate athletics, but only that the examiner did not find medical reason to disqualify
me from participation.
_______________________________________
_______________________
Signature of Student-Athlete
Date
_______________________________________
_______________________
Signature of Parent/Guardian if under 18 years of age
Date
MEDICAL CONSENT
Permission is hereby granted to the attending physician, USF Sports Medicine Staff, or other medical
personnel to proceed with medical treatment, minor surgical treatment, and x-ray examination. In the
event of serious injury or illness, I understand that an attempt will be made by the appropriate medical
personnel to contact my parents or legal guardian. If medical personnel are not able to communicate
with the responsible party, the treatment necessary for my health will be provided.
_______________________________________
________________________
Signature of Student-Athlete
Date
_______________________________________
________________________
Signature of Parent/Guardian if under 18 years of age
Date
Student-Athlete Health Insurance Information Form
Dear Parent/Guardian:
We have an established athletic insurance policy providing medical coverage for your son/daughter for injuries that occur while participating in Intercollegiate Athletics. This medical coverage is secondary to medical/dental/vision insurance provided by the parent/guardian. After primary benefits are considered, USF will process the remaining balance for payment. Please complete this form entirely. Please attach copies of all insurance cards, front and back.
StudentAthlete_________________________________________Sport________________________DOB____________ USF I.D._______________________________
Local Phone Number (___) _______________________ Cell Phone Number (___)________________________ If Uninsured initial here: _______
Insurance Subscriber Name______________________________________________________SS#________________DOB________ Address_____________________________________________________________________________________________________ Employer_________________________________________________Work.Phone_________________________________________ Athlete’s Relationship to Subscriber ____________________________
Primary Medical Insurance
Insurance.Company__________________________________________ Customer.Service#__________________________________ Claims.Address_______________________________________________________________________________________________ Member#______________________________________Policy#________________________Group#__________________________ PPO or HMO____________ Primary Care Physician____________________________ Phone#_______________________________
Secondary Insurance
(circle one) Prescription, Dental, VisionInsurance.Company___________________________________________Customer.Service#_________________________________ Claims.Address_______________________________________________________________________________________________ Member#_____________________________________Policy#_________________________Group#__________________________ PPO or HMO____________ Primary Care Physician_____________________________ Phone#______________________________
Secondary Insurance
(circle one) Prescription, Dental, VisionInsurance.Company___________________________________________Customer.Service#_________________________________ Claims.Address_______________________________________________________________________________________________ Member#_____________________________________Policy#_________________________Group#__________________________ PPO or HMO____________ Primary Care Physician______________________________ Phone#_____________________________
IN CASE OF EMERGENCY CALL
Name: ____________________________ Relationship: ____________________________ Address: _____________________________________________________________________________ Home Phone #: (____) _________________ Work Phone #: (____) ____________________ Cell Phone #: (____) _________________
I acknowledge receiving the University of South Florida’s intercollegiate athletic medical policy. I understand the university’s responsibility to a student athlete who becomes injured or ill as a result from participation in intercollegiate athletics.
BIOLOGICAL SPECIMEN TESTING CONSENT FORM
1. I hereby consent to be tested to determine if I have utilized any substance on the University of South Florida list of banned drug classes as set forth in the University of South Florida’s Substance and Abuse Policy, by providing a biological specimen as requested by the director of intercollegiate athletics or designee.
2. I agree to provide such biological specimens at the time and location and under conditions for collection, as determined by the director of intercollegiate athletics or designee, at various times throughout the year, with or without prior notice.
3. I hereby authorize the director of intercollegiate athletics or designee to send my samples to the laboratory of the university’s choice for actual testing and authorize the director of intercollegiate athletics or designee to receive test results.
4. I hereby authorize the director of intercollegiate athletics or designee to release all information and records, including test results, that may be made or received relating to the screening and testing of my biological specimens to the university’s respective head coach and associate athletic director for sports and program services, or their designees, for their use in supervision and administration of the university’s athletic program. I acknowledge that while certain medical information may be released to the media by virtue of my participation in USF Intercollegiate Athletics, the results of drug tests will not be released or reported. I further acknowledge and agree that my parent/ guardian will be notified of the results of any positive test result(s).
5. I acknowledge that I have read a copy of the University of South Florida Drug Abuse Policy and Procedures,
including the University of South Florida Banned Drug Class List, and that I have had an opportunity to ask questions regarding them. I understand the provisions therein and I agree to abide by those provisions including those
specifically related to possible penalties for positive test results.
6. I hereby release and discharge the University of South Florida and the Board of Trustees of the State University System of South Florida, their officers, employees and agents from all claims and causes of action created by or arising out of any act or omission related to the implementation of the University of South Florida Drug Abuse Policy and procedures.
7. I have read this Consent Form, understand the terms in it, their legal significance and sign voluntarily.
8. I understand that I may revoke my consent to participate at any time in the University of South Florida Drug Abuse Policy. In doing so, I understand and agree that I will immediately be banned from participation in intercollegiate athletics at University of South Florida and will immediately forfeit any related athletic scholarships or financial aid.
_______________________________________ ____________________________
Student Athlete Name (Print) USF ID Number
_______________________________________ ______________________________
Student-Athlete Signature Date Birth Date ___________________________________________ ______________________________ Parent / Guardian (if under 18 years of age) Date
_____________________________ Sport
INFORMATION RELEASE AUTHORIZATION
I, _____________________, Give consent for my medical records to be released to any USF Team physician
involved in the care of my illness or injury; or to a physician appointed by the USF Athletic Training Staff.
Athlete’s Signature: _________________________ Date: ___/___/___
I also give consent for the USF Athletic Training Staff to release medical information to the sports information
department, media, or a scout/ representative of any professional or amateur athletic organization seeking such
information. I acknowledge that this type of information may be reported in the media as a result of my
participation in USF Intercollegiate Athletics, except that no results of drug tests will be released or reported.
(Body part affected by injury or illness
(
Nature of the injury (sprain, fracture, etc.)
(
Status of the athlete for same day and future competition
Athlete’s Signature: _______________________ Date: ___/___/___
***This release remains valid until revoked in writing and delivered to the Assistant Director of Athletics for
Sports Medicine.
For purposes of this authorization, medical information can include but not be limited to, information
concerning illness, injury, treatment, rehabilitation, physicians’ names or referrals, and/or prognosis.
SUPPLEMENT/MEDICATION WAIVER
I will not consume any nutritional supplement* other than those provided or having written approval from
Athletic Department Sport Performance staff, Assistant AD/Head Strength & Conditioning Coach or Assistant
AD/Director of Sports Medicine.
I will notify Sports Medicine staff and Team Physicians of any current prescription medications I am presently
taking prior to receiving any OTC* and Prescription medications* from Sports Medicine staff.
*Nutritional supplement is any product (powder, pill, liquid, beverage, tablet, etc.) designed to supplement the diet which includes one or more of the following ingredients: vitamins, minerals, herbs, botanicals, amino acids, calorie boosters, constituents, extracts, or any combination of these ingredients.
*OTC medications are medications that can be purchased over the counter from retailers such as drug stores, pharmacies, grocery stores and convenience stores. A prescription is not needed for these medications. Typical OTC medications include Tylenol, aspirin, ibuprofen, cough and cold formulas, and medications for allergies, constipation, diarrhea and nausea.
*Prescription medications are generally more potent than those sold over-the-counter (OTC) and may have more serious side effects if inappropriately used. Therefore, these medications are only sold under a doctor’s direction.
All supplements must be approved by the three individuals listed above. Please list supplements/medication you
are currently taking or have taken in the past 3 months:
1.
2.
3.
4.
5.
6.
Print Name:__________________ Signature:___________________ Date:_________
LIABILITY WAIVER
I, ___________________________, understand that there are risks in participating in the sport of
_________________________. I am voluntarily assuming the responsibility for any such risks. Therefore, I
consent to receive any emergency medical treatment deemed necessary by the Sports Medicine staff at the
University of South Florida and agree that the Sports Medicine staff may terminate my participation at any time
and for any reason. I waive and release the University of South Florida, the Board of Trustees (or any other entity
designated by Florida law to manage, operate, and/or oversee the University of South Florida) and the officers,
agents, employees, and any students acting on behalf of either the University of South Florida or the Board of
Trustees, and the heirs, assigns or successors in interest of any and each of them from any and all Liability which
may result or arise from either my athletics participation or any medical treatment I may receive. If any portion
on this Release is held to be illegal, unenforceable, or in conflict with any laws of the State of Florida by any
Court of competent jurisdiction, the remaining portions of this release shall not be affected.
_____________________________
________________________
Signature of Participant
Date
_____________________________
________________________
USF ID Number
Date of Birth
_____________________________
________________________
Signature of Parent/Guardian if
Date
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO INDIVIDUALS WITHIN AND
ASSOCIATED WITH THE USF ATHLETIC DEPARTMENT
This authorizes the athletic trainers, team physicians and athletics staff including coaches representing the University of South Florida to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information to the following INDIVIDUALS associated within and associated with the USF Athletic Department and for the following purposes:
• INDIVIDUALS: Student athletic trainers and other students who are participating in the provision of sports medicine
healthcare. PURPOSE: to allow such student athletic trainers and other students participating in the delivery of sports medicine healthcare to assist and participate in the provision of healthcare to me while I am a student athlete.
• INDIVIDUALS: My teammates. PURPOSE: to advise them of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they will be aware of limitations that I may be under while I am a student athlete.
• INDIVIDUALS: My coaches, assistant coaches and other team related athletics staff. PURPOSE: to advise the coaches and athletics staff of the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may make decisions regarding my athletic ability and suitability to compete while I am a student athlete.
• INDIVIDUALS: My Parents and/or Guardians. PURPOSE: to advise my parent/guardian of the nature, diagnosis,
prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may assist me in making healthcare decisions while I am a student athlete.
This information that may be disclosed includes injuries or illnesses relevant to past, present or future participation in athletics at the University of South Florida. I understand that the entities that receive the information are not health care providers or health plans covered by federal privacy regulations, and that the information described above may be re-disclosed publicly and that the information will no longer be protected by those regulations.
I understand that the University of South Florida will not receive compensation for its use/disclosure of the information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this authorization.
I understand that I may revoke this authorization in writing at any time by notifying in writing the Assistant Athletic Director for Athletic Training, but if I do, it will not have any effect on actions the University of South Florida took in reliance on this authorization prior to receiving the revocation. This authorization expires six years from the date it is signed.
_____________________________ ________________________ Printed Name of Student-Athlete Sport
______________________________ Date of Birth
______________________________ ________________________ Signature of Student-Athlete Date
______________________________ ________________________ Signature of Parent/Legal Guardian Date
(If Student-Athlete is under 18 years of age)
NOTICE OF PATIENT INFORMATION PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR
DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION.
PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, to be kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, the University of South Florida has prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We participate in this notification, and will share protected health information (PHI), as necessary, to carry out treatment, payment, or
healthcare operations.
USES AND DISCLOSURES OF HEALTH INFORMATION
The University of South Florida may use and disclose your protected health information for treatment, obtaining payment for treatment, and healthcare operations necessary to sustain our business.
Ø Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.
An example of this would be:
o A physical examination or assessment.
Ø Payment means such activities as obtaining reimbursement for services, confirmation coverage, billing or collection activities and utilization review.
An example of this would be:
o We may provide information to your insurance company as needed to receive payment for services rendered to you. This may include, but is not limited to, diagnosis and treatment codes, treatment notes, and copies of documentation relevant to obtaining payment. Your insurance company, health plan, health insurance issuer or HMO with respect to a group health plan, may disclose protected health information to the sponsor of the plan.
Ø Healthcare Operations includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost -management analysis, and customer service.
An example of this would be:
o We may use your personal information to contact you to remind you of an upcoming appointment, either by phone or by mail.
Some of the services we offer may be provided to you in a semi-private setting. For example, our Sports Medicine Clinic and Therapy Departments have an open gym area that allow athletic trainers and patients efficient access to equipment and modalities needed and shared by the department.
The University of South Florida may use or disclose your protected health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
In any other situation, the University of South Florida’s policy is to obtain your written authorization before disclosing your protected health information. An example of this would be a release to the media in regards to a specific injury or illness. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time.
The University of South Florida may change its policy at any time. This amendment will affect all protected health information maintained by the University of South Florida. When changes are made, a new Notice of Patient Information Practices will be posted in the training room areas that will display the Effective Dates and any Revision Dates, and will be provided to you on your next visit. You may also request an updated copy of our current Notice of Patient Information Practices at any time.
PATIENT’S INDIVIDUAL RIGHTS
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
Ø You have the right to review or obtain a copy of your protected health information at any time.
Ø You have the right to request restrictions on certain uses and disclosures of protected health information,
including those related to disclosure of family member, other relatives, close personal friends or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a
restriction, we must abide by it unless you agree in writing to remove it. You may also request in writing that we not use or disclose your protected health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. The University of South Florida will consider all such requests on a case-by-case basis, but the practice is not legally required to accept them.
Ø You have the right to request that we amend your protected health information.
Ø You also have the right to request a list of instances where we have disclosed your protected health information for reasons other than treatment, payment or other related administrative purposes.
Ø You have the right to obtain a paper copy of this notice from us upon request.
CONCERNS AND COMPLAINTS
If you are concerned that the University of South Florida may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your protected health information, please contact our Privacy Officer or Quality Assurance Department at the address listed below. It is our intent to protect and keep your protected health information confidential. Your alerting us of any concerns you may have is a necessary part of a continuous quality process we employ. You will, in no way, be retaliated against for filing a complaint. You may also send a written complaint to the US Department of Health and Human Services. For further information on the University of South Florida’s health information practices or if you have a complaint, please contact the following person:
University of South Florida Sports Medicine Privacy Officer: Steve Walz M.A., ATC, LAT
Assistant Athletic Director Director of Sports Medicine University of South Florida
ATH 100 (813) 974-3506
By signing this form I acknowledge that I have read and received the Notice of Patient Information Privacy
Practices from the University of South Florida Sports Medicine Staff.
I understand my rights as a patient and further understand that the University of South Florida
Sports Medicine Staff may change their Notice of Privacy Practices at any time. If a change in
this policy does occur, I understand that I will be notified in a timely manner.
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Student-Athlete Name (Print) Date
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Student-Athlete Signature_______________________________
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Parent/Guardian Signature (if under 18 years of age) Date
MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION
GUIDELINES
Concussion Management
The following are general guidelines based on the recommendations of the NCAA and National Athletic
Trainers Association to be followed by all Certified Athletic Trainers when dealing with concussions:
1.
Student-athletes will be provided educational material regarding concussions and will be required to
sign a statement, at the time of or as close as possible to pre-participation examinations, in which the
student-athlete accepts the responsibility for reporting their injuries and illnesses to the institutional
medical staff, including signs and symptoms of concussions.
2.
At the time of injury, the ATC should document all information pertinent to the concussive event
including 1) mechanism of injury; 2) initial signs and symptoms; 3) state of consciousness; 4) findings
on serial neurological testing (SCAT2 test).
3.
The ATC should monitor vital signs and level of consciousness after a concussion until the athlete’s
condition improves.
4.
An athlete with a concussion should be referred to a physician / emergency room on the day of injury if
he or she lost consciousness, experienced amnesia lasting longer than 15 minutes, vomited, experiences
increased symptoms or experiences persistent decreased sensory or motor function.
5.
An athlete with a mild concussion who has an increase in the number of post concussion symptoms, or
the symptoms worsen over time or the symptoms interfere with the athlete’s daily activities should be
referred to a physician.
6.
An athlete should be disqualified from competition on the day of injury if he/she experiences concussion
symptoms, loss of consciousness or amnesia.
7.
The University of South Florida Sports Medicine Staff / Team Physician will establish guidelines for
return to activity for athletes who sustain a concussion and/or continue to have symptoms following
initial injury.
8.
An athlete with a history of concussion should be treated more conservatively; the severity of the
concussion may require the athlete to see a physician.
9.
An athlete who is sent home with a mild concussion should be given instructions for home care.
10. An athlete who suffers a diagnosed concussion will only be eligible to return to play following direct
consultation, evaluation and clearance from a University of South Florida Team Physician and/or his/her
designee.
MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION
GUIDELINES
University of South Florida Sports Medicine personnel will evaluate mild traumatic brain injured / concussive
student-athletes as follows-
Baseline Testing- testing to be completed at the time of or as close to the student-athlete’s pre-participation
physical examination as possible.
a) Concussion Assessment Tool- SCAT2 b) Neuropsychological Assessment – ImPACT
INJURY MANAGEMENT
Time of Injury-
a) Mild Traumatic Brain Injury Initial Evaluation b) Post Concussion Symptom Scale
c) SCAT2 test (if applicable and available)
d) Physician Evaluation (if applicable and available)
Note: Any student-athlete that serially exhibits signs/symptoms, or behaviors consistent with a concussive injury, including, but not limited to:
1) Loss of consciousness;
2) Confusion, as evidenced by disorientation to person, time, or place; inability to respond appropriately to questions; inability to process information correctly and/or respond appropriately to analytical questions; or inability to remember assignments and/or plays;
3) Amnesia (anterograde and/or retrograde; immediate or delayed);
4) Abnormal neurological examination (i.e. abnormal papillary response, persistent dizziness or vertigo, abnormal balance, etc.) 5) New and persistent headache, particularly if accompanied by photosensitivity or other visual disturbances, tinnitus, nausea,
vomiting, or dizziness; and/or
6) Any other persistent signs or symptoms of a concussive injury should be withheld from participation for the remainder of that day.
Once removed from participation, the student-athlete must follow the outlined guidelines for management of his/her injury and will not be considered for return to participation until he/she is fully asymptomatic at both rest and exertion, post-exertion assessments are within normal baseline limits, and he/she has been cleared for participation by the University of South Florida Team Physician and/or his/her designee.
MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION
GUIDELINES
Post- Concussion Follow-Up
(24-hours post-injury)
-
a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale c) SCAT2 Test
d) Neuropsychological Assessment – ImPACT e) Physician evaluation and/or consultation
Note-
The Mild Traumatic Brain Injury Evaluation Form / Post Concussion Symptom Scale will be repeated every day until the student-athlete Self-Reports Asymptomatic (SRA), at which time the student-athlete will begin with Day 1 SRA Procedures. During the period of recovery and while the student-athlete is symptomatic following injury, the student-athlete should engage in physical AND cognitive rest until such time that he/she is asymptomatic.
Post- Concussion Follow-Up
(48-hours post-injury)
-
a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale c) SCAT2 Test
d) Neuropsychological Assessment – ImPACT
e) Physician evaluation and/or consultation (as needed and/or warranted)
Post- Concussion Follow-Up
(7-days post-injury)
-
a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale c) SCAT2 Test
Day 1 Self-Report Asymptomatic (SRA)
a) Mild Traumatic Brain Injury Evaluation b) Post Concussion Symptom Scale
c) Neuropsychological Assessment – ImPACT d) SCAT2 Test
e) Cardiovascular exercise in controlled setting- (see sample protocol)
• Mode, duration and intensity dependant upon sport
• Monitor symptomology
o If student-athlete becomes symptomatic, return the student-athlete to the concussed state / procedures until they Self-Report Aysmptomatic (SRA)
Note-
If the athlete develops any post-concussion symptoms during the Day 1 SRA Testing, the student-athlete should immediately stop all activity and rest for a minimum of 24 hours and until asymptomatic. After the minimum 24-hour rest period and once the student-athlete is asymptomatic, he/she should resume testing as per the Day 1 SRA Exertional Testing Protocol.
MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUSTION
GUIDELINES
Day 2 Self-Report Asymptomatic
(SRA)-a) Mild Traumatic Brain Injury Evaluation / Post Concussion Symptom Scale b) Sports-Specific Functional Activity
• Mode, duration and intensity dependant upon sport Note-
If the athlete develops any post-concussion symptoms during the Day 2 SRA Testing, the student-athlete should immediately stop all activity and rest for a minimum of 24 hours and until asymptomatic. After the minimum 24-hour rest period and once the student-athlete is asymptomatic, he/she should resume testing as per the Day 1 SRA Exertional Testing Protocol.
Day 3 Self-Report Asymptomatic
(SRA)-a) Mild Traumatic Brain Injury Evaluation / Post Concussion Symptom Scale b) Supervised “non-contact” practice
Note-
If the athlete develops any post-concussion symptoms during the Day 3 SRA Testing, the student-athlete should immediately stop all activity and rest for a minimum of 24 hours and until asymptomatic. After the minimum 24-hour rest period and once the student-athlete is asymptomatic, he/she should resume testing as per the Day 2 SRA Exertional Testing Protocol. IF the student-athlete is asymptomatic with all activity on Day 3 SRA, consult with the Team Physician for return to play clearance.
Day 4 Self-Report Asymptomatic
(SRA)-a) Provided that the student-athlete has achieved a full resolution of symptoms, passed the functional progression without recurrence of symptoms and received clearance from a University of South Florida Team Physician and/or his/her designee, the athlete may return to full contact, unrestricted, supervised practice.
RETURN TO PLAY PROGRESSION
Post-Concussion Exertional Testing Protocol Guidelines-Return To Play-
In order to be considered for return to play, the student-athlete must- 1. Follow the outlined guidelines for management of his/her injury;
2. Be fully asymptomatic at rest, with exertional testing, and with supervised non-contact and contact sports-specific activities.
3. Be within normal baseline limits on all post-exertion assessments; and
4. Be cleared for participation by the University of South Florida Team Physician and/or his/her designee.
All testing is to be done in a controlled setting and under the direct supervision of a certified athletic trainer.
• Monitor symptomology.
• If the student-athlete self-reports asymptomatic, proceed to the next level. • If the student-athlete reports symptoms at any time.
a. STOP THE TESTING PROTOCOL
b. Rest for a minimum of 24 hours and until asymptomatic
c. After the minimum 24 hour rest period and when asymptomatic, resume testing at the beginning of the last asymptomatic level.
Exertional Testing Protocol-
Level 1 (Sub-Maximal Cardiovascular Training)- [preferably indoors] • Exercise elliptical trainer/ Stationary bike
• Duration- 15 minutes
• 65% maximal heart rate (220 – age x .65 = target heart rate) Level 2 (Maximal Cardiovascular Training)-
• Exercise elliptical trainer/ Stationary bike • Duration- 20 minutes
• 85% maximal heart rate (220 – age x .85 = target heart rate) Level 3 (Sub Maximal Anaerobic Training)
• Sit-ups and/or crunches
• One (1) minute continuous exercise Level 4 (Maximal Effort Anaerobic Training)-
• 300 yard shuttle run Level 5 (Weight Training)-
• Mode, duration and intensity dependent upon sport
• If Day 2 does not fall within the student-athlete’s scheduled weight lifting schedule, the
