Dear Parent/Guardian,

Northeast Rehabilitation Hospital Network and Pelham High School are currently implementing an innovative program for our student-athletes.  This program will assist our athletic trainer and others involved with the healthcare of your son/daughter in evaluating and treating head injuries (e.g., concussion).  In order to better manage concussions sustained by our student-athletes, we have acquired 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 an 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 athletes at the beginning a contact sport season. Contact sports are defined by the American Academy of Pediatrics Classification of Sports According to Contact.  The list of contact sports is as follows: football, girls and boys soccer, field hockey, cheerleading, girls and boys diving, girls and boys basketball, girls and boys ice hockey, wrestling, girls and boys gymnastics, girls and boys skiing, girls and boys lacrosse and ultimate Frisbee (if varsity sport).  This non-invasive test is set up in “video-game” type format and takes about 15-20 minutes to complete.  It is simple, and actually many athletes enjoy the challenge of taking the test. Essentially, the ImPACT test is a preseason physical of the brain.  It tracks information such as memory, reaction time, speed, and concentration.  It, however, is not an IQ test.

If a concussion is suspected, the contact sport athlete will be required to re-take the test.  Both the preseason and post-injury test data is given to the athletic trainer and consulting clinicians, to help evaluate the injury.  If a limited contact sport athlete or a noncontact sport athlete is suspected of having a concussion they too will be tested and compared to baseline normative data.  The information gathered can also be shared with your family doctor.  The test data will enable these health professionals to determine when return-to-play is appropriate and safe for the injured athlete.  If an injury of this nature occurs to your child, you will be promptly contacted with all the details.

We wish to stress that the ImPACT testing procedures are non-invasive, and they pose no risks to your student-athlete.  We are excited to implement this program given that it provides us the best available information for managing concussions and preventing potential brain damage that can occur with multiple concussions. The administration, coaching, and athletic trainer are striving to keep your child’s health and safety at the forefront of the student athletic experience.  Please return the attached page with the appropriate signatures.  If you have any further questions regarding this program please feel free to contact the Athletic Director or Athletic Trainer.

Consent Form

For use of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

I have read the attached information.  I understand its contents.  I have been given an opportunity to ask questions and all questions have been answered to my satisfaction.  I agree to participate in the ImPACT Concussion Management Program.

Printed Name of Athlete      _________________________­­__________

          Athlete date of birth   ___________________________

 Sports                                      __________________________­­_________