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LYBL Concussion Form


Player / Parent Concussion Advisory Form

This advisory form was developed to provide parents of players with current and relevant information regarding concussions and to comply with Connecticut General Statutes (C.G.S.) Chapter 163, Section 149b: Concussions:  Training courses for coaches.  Education plan.  Informed advisory form.  Development or approval by the State Board of Education and Section 10-149c: athletes and concussions.  Removal from athletic activities.  Notification of parent or legal guardian.  Revocation of coaching permit.


What is a Concussion?

National Athletic Trainers Association (NATA) - A concussion is a “trauma induced alteration in mental status that may or may not involve loss of consciousness.”

Centers for Disease Control and Prevention (CDC) - “A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth.” -CDC, Heads Up: Concussion  

Even a “ding,” “getting your bell rung,” or what seems to be mild bump or blow to the head can be serious” -CDC, Heads Up: Concussion Fact Sheet for Coaches


Section 1.  Concussion Education Plan Summary

The Concussion Education Plan and Guidelines for Connecticut Schools was approved by the Connecticut State Board of Education in January 2015.  Below is an outline of the requirements of the plan.  The complete document is accessible on the CSDE Web site:


State law requires that each local and regional board of education must approve and then implement a concussion education plan by using written materials, online training or videos, or in-person training that addresses, at a minimum the following:

  1. The recognition of signs or symptoms of concussion.
  2. The means of obtaining proper medical treatment for a person suspected of sustaining a concussion.
  3. The nature and risks of concussions, including the danger of continuing to engage in athletic activity after sustaining a concussion.
  4. The proper procedures for allowing a player athlete who has sustained a concussion to return to athletic activity.
  5. Current best practices in the prevention and treatment of a concussion.


Section 2.  Signs and Symptoms of a Concussion:  Overview

A concussion should be suspected if any one or more of the following signs or symptoms are present, or if the coach/evaluator is unsure, following an impact or suspected impact as described in the CDC definition above.


Signs of a concussion may include (i.e. what the athlete displays/looks like to an observer):

·         Confusion/disorientation/irritability

·         Trouble resting/getting comfortable

·         Lack of concentration

·         Slow response/drowsiness

·         Incoherent/ slurred speech

·         Slow/clumsy movements

·         Loses consciousness

·         Amnesia/memory problems

·         Acts silly/combative/aggressive

·         Repeatedly ask same questions

·         Dazed appearance

·         Restless/irritable

·         Constant attempts to return to play

·         Constant motion

·         Disproportionate/inappropriate reactions

·         Balance problems


Symptoms of a concussion may include (i.e. what the athlete reports):

·         Headache or dizziness

·         Nausea or vomiting

·         Blurred or double vision

·         Oversensitivity to sound/light/touch

·         Ringing in ears

·         Feeling foggy or groggy


State law requires that a coach MUST immediately remove an athlete from participating in any athletic activity who:  a) is observed to exhibit signs, symptoms or behaviors consistent with a concussion following a suspected blow to the head or body, or b) is diagnosed with a concussion, regardless of when such concussion or head injury may have occurred.  Upon removal of the athlete, a qualified league person must notify the parent or legal guardian within 24 hours that the player athlete has exhibited signs and symptoms of a concussion.

Section 3.  Return to Play (RTP) Protocol Overview

Currently, it is impossible to accurately predict how long an individual’s concussion will last.  There must be full recovery before a player is allowed to resume participating in athletic activity.  Connecticut law now requires that no athlete may resume participation until they have received written medical clearance from a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN), athletic trainer) trained in the evaluation and management of concussions.


Concussion Management Requirements:

1.     No athlete SHALL return to participation in the athletic activity on the same day of concussion.

2.     If there is any loss of consciousness, vomiting or seizures, the athlete MUST be immediately transported to the hospital.

3.     Close observation of an athlete MUST continue following a concussion.  The athlete should be monitored for an appropriate amount of time following the injury to ensure that there is no worsening/escalation of symptoms.

4.     Any athlete with signs or symptoms related to a concussion MUST be evaluated by a licensed health care professional (physician, physician assistant, advanced practice registered nurse (APRN)) trained in the evaluation and management of concussions. 

5.     The athlete MUST obtain an initial written clearance from one of the licensed health care professionals identified above directing her/him into a well-defined RTP stepped protocol similar to the one outlined below. If at any time signs or symptoms return during the RTP progression, the athlete should cease activity.

6.     After the RTP protocol has been successfully administered (no longer exhibits any signs or symptoms or behaviors consistent with concussions), final written medical clearance is required by one of the licensed health care professionals identified above for the athlete to fully return to unrestricted participation in practices and competitions.


Medical Clearance RTP protocol (For Ledyard Youth Basketball League)

Rehabilitation stage

Functional exercise at each stage of rehabilitation

Objective of each stage

1. No activity

Complete physical and cognitive rest until asymptomatic.


2. Full activity

No restrictions (Requires A Doctor’s Signed Release)

Return to full athletic participation


The player’s doctor may permit return to partial activities.  This also must have a written protocol for what the player may or may not do on any given day from incident to returning to full participation.  The player’s coach must have a copy of the written instructions for limited activities and when fully cleared to return.


I have read and understand this document the “Player and Parent Concussion Advisory Form” and understand the severities associated with concussions and the need for immediate treatment of such injuries.



Player name: ______________________________ Date ______     _ Signature __________________________

                                          (Print Name)


I authorize my child to participate in ____________________   __ for the Ledyard 2017-2018 Season



Parent/Guardian name: ___________________________ Date _______  Signature_______________________

                                                (Print Name)


1.     NFHS. Concussions. 2008 NFHS Sports Medicine Handbook (Third Edition). 2008: 77-82.

  1. Centers for Disease Control and Prevention. Heads Up: Concussion in High School / town Sports.
  2. CIAC Concussion Central -



·         Centers for Disease Control and Prevention. Injury Prevention & Control: Traumatic Brain Injury. Retrieved on June 16, 2010.

·         Centers for Disease Control and Prevention. Heads Up: Concussion in High School / town Sports Guide for Coaches. Retrieved on June 16, 2014.