Concussion Assessment in Youth Athletes

CONCUSSION ASSESSMENT IN YOUTH ATHLETES

CONSENT FORM

For questions regarding this study, Michigan State University’s Human

Please contact: Research Protection Program

Tracey Covassin, Ph.D., ATC 408 West Circle Drive #207

Department of Kinesiology Michigan State University

Michigan State University East Lansing, MI 48824

Phone: (517) 353-2010 E-mail:

E-mail: Phone: (517) 355-2180

Fax: (517) 432-4503

Ryan Moran, M.S., ATC,

Department of Kinesiology

Michigan State University

Phone: (215) 896-3693

E-mail:

Purpose:

The purpose of this research study is to collect normative data for youth athletes on the Vestibular-Ocular Motor Screening (VOMS) and King-Devick (KD) assessment, two recently developed sideline concussion tests. Some athletes have numerous symptoms and impairments following concussion, such as headache, dizziness, nausea, and fogginess, along with visual impairments, which this test will provide data for how non-concussed athletes perform.

General Experimental Procedures:

Your child will complete two sideline baseline concussion tests: the VOMS test and the KD test. The VOMS test consists of your child sitting and following the researchers finger, looking back and forth between two fingers, and starring at an object while moving their head as if they are signaling “no” or “yes”. Their symptoms of headache, dizziness, nausea, and fogginess will be recorded. The KD tests involves reading 2 or 3 sets of numbers as quickly as possible and their time will be recorded. Total test time is 5-10 minutes. You as the parent, will be asked to complete s short health related form pertaining to concussion.

Possible Risk:

This study involves minimal risk to your child. Risks associated with completing the tasks are frustration from errors reading numbers.

Benefits:

You child’s test performance will help add to the evidence of concussion research in the youth population, one that is very important and not heavily investigated. Please contact Dr. Covassin by phone or email if you would like to discuss the assessment results of your child

Confidentiality:

You and your child’s participation in this study are completely voluntary. The only people who have access to the results are the researchers and HRPP. You and your child’s identity and information recorded during the study will remain confidential. Confidentiality will be protected by; (a) results of this study may be published or presented at professional meetings, but the identities of all research participants will remain confidential; and (b) all data will be stored in a computer that is password protected, as well as informed consent, and concussion measures will remain in an office under double lock and key for 3 years after the study ends. You and your child’s privacy will be protected to the maximum extent allowable by law.

The Right to Get Help if Injured:

If your child is injured as a result of his/her participation in this research project, Michigan State University will assist your child in obtaining emergency care, if necessary, for his/her research related injuries. If you have insurance for medical care, your insurance carrier will be billed in the ordinary manner. As with any medical insurance, any costs that are not covered or in excess of what are paid by your insurance, including deductibles, will be your responsibility. The University's policy is not to provide financial compensation for lost wages, disability, pain or discomfort, unless required by law to do so. This does not mean that you are giving up any legal rights you may have. You may contact Dr. Tracey Covassin at 517-353-2010 with any questions or to report an injury.

Voluntary Participation:

You and your child’s participation in the research study is voluntary. Refusal to participate will involve no penalty or loss of benefit to which you are otherwise entitled. You may discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled.

Institutional Contacts:

If you have concerns or questions about this study, such as scientific issues, how to do any part of it, or to report an injury, please contact the researcher Tracey Covassin (517)-353-2010 or email at or regular mail at Department of Kinesiology, Michigan State University, East Lansing, MI 48824. If you have questions or concerns about your role and rights as a research participant, would like to obtain information or offer input, or would like to register a complaint about this study, you may contact, anonymously if you wish, the Michigan State University’s Human Research Protection Program at 517-355-2180, Fax 517-432-4503, or e-mail or regular mail

at Olds Hall, 408 West Circle Drive #207, MSU, East Lansing, MI 48824. Your signature below indicates your voluntary agreement to participate in this study.

I, ______, have read and agree to allow my child ______,

(Please Print Your Name) (Please print your child’s name)

to participate in this study as described above.

______/______/______

Adult Signature Date

PLEASE BRING THIS PAGE AND THE NEXT 2 PAGES WITH YOU SIGNED, TO THE NEXT PRACTICE.

PLEASE CONTINUE AND COMPLETE QUESTIONNAIRE ON NEXT PAGE

NAME OF CHILD: ______

GENDER: ____Male ____Female

AGE: _____

HEIGHT: ______feet ______in. WEIGHT: ______lbs.

SCHOOL/ORGANIZATION: ______

SPORT: ______

______

Please ‘CIRCLE’ yes or no for the following questions. If yes, please answer.

Has your child ever been diagnosed with a concussion? Yes No

If YES, how many? ______

Has your child ever been diagnosed with headaches or migraines? Yes No

Does your child have a learning disability,

dyslexia, ADHD/ADD or seizure disorder? Yes No

If YES, are they on medication: Yes No

Has anyone in your family ever been diagnosed

with any aforementioned problems? Yes No

If YES, explain:

PLEASE HAVE CHILD SIGN FORM ON NEXT PAGE

CONCUSSION ASSESSMENT IN YOUTH ATHLETES

ASSENT FORM

For questions regarding this study, Michigan State University’s Human

Please contact: Research Protection Program

Tracey Covassin, Ph.D., ATC 408 West Circle Drive #207

Department of Kinesiology Michigan State University

Michigan State University East Lansing, MI 48824

Phone: (517) 353-2010 E-mail:

E-mail: Phone: (517) 355-2180

Fax: (517) 432-4503

Ryan Moran, M.S., ATC,

Department of Kinesiology

Michigan State University

Phone: (215) 896-3693

E-mail:

Purpose:

The purpose of this study is to test vision and movement on one concussion test and see how fast you can read a series of numbers on another test.

Consent:

You have been chosen to be in this research study because you are a youth athlete. Your participation in the research study is voluntary. You have the right to say no. If you choose not to be in the study, it will not affect your sport participation. You may stop participation in this study at any time.

General Experimental Procedures:

You will do quick tests: a vision and head movement test (3 minutes) and a test reading numbers (2 minutes). Throughout the test you will be asked if you have a headache, feel like you are spinning, feel sick, or feel slowed down.

Your signature below indicates your voluntary agreement to be in this study.

I, ______, have read and agree to be in this study.

(Please Print Child Name)

______/______/______

(Child Signature) (Date)