Concussion Info Sheet-Signature Required




Dear Parent/Guardian and Athletes,

This information sheet is provided to assist you and your child in recognizing the signs and symptoms of a concussion. Every athlete is different and responds to a brain injury differently, so seek medical attention if you suspect your child has a concussion. Once a concussion occurs, it is very important your athlete return to normal activities slowly, so he/she does not do more damage to his/her brain.

What is a Concussion?

A concussion is an injury to the brain that may be caused by a blow, bump, or jolt to the head. Concussions may also happen after a fall or hit that jars the brain. A blow elsewhere on the body can cause a concussion even if an athlete does not hit his/her head directly. Concussions can range from mild to severe.

Signs and Symptoms of a Concussion

Athletes do not have to be “knocked out” to have a concussion. In fact, less than 1 out of 10 concussions result in loss of consciousness. Concussion symptoms can develop right away or up to 48 hours after the injury. Ignoring any signs or symptoms of a concussion puts your child’health at risk!

Signs Observed by Coaches, Officials, Parents or Guardians

Appears dazed, stunned or confused
Unsure about event, location of name of meet
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows behavior or personality changes-irritability, sadness, nervousness, emotional
Can’t recall events before or after incident

Symptoms Reported by Athlete

Any headache or “pressure” in head-how badly it hurts does not matter
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light and/or noise
Feeling sluggish, hazy, foggy or groggy
Concentration or memory problems
Does not “feel right”
Trouble falling asleep
Sleeping more or less than usual


Be Honest

Seek Medical Attention Right Away

Seeking medical attention on the day of the event is an important first step if you suspect or are told your swimmer has a concussion. A qualified health care professional will be able to determine how serious the concussion is and when it is safe for your child to return to sports and other daily activities:

No athlete should return to activity on the same day he/she gets a concussion
No athlete may return to training, regardless of sport, until he/she is cleared by a heath care professional with a note specifying clearance. Athletes should NEVER return to the pool
if they still have ANY symptoms....... in case an athlete returns with a note and then during the practice complains of a headache or other symptoms
Parents and coaches should never pressure any athlete to return to play

The Dangers of Returning Too Soon

Returning to the pool too early may cause Second Impact Syndrome (SIS) or Post-Concussion Syndrome (PCS). SIS occurs when a second blow to the head happens before an athlete has completely recovered from a concussion. This second impact causes the brain to swell, possibly resulting in brain damage, paralysis, and even death. PCS can occur after a second impact. PCS can result in permanent, long-term concussion symptoms. The risk of SIS and PCS is the reason why no athlete should be allowed to participate in any physical activity before they are cleared by a qualified health care professional.


A concussion can affect school, work, and sports. Along with coaches and teachers, the school nurse, athletic trainer, employer, and other school administrators should be aware of the athlete’injury and their roles in helping the child recover. During the recovery time after a concussion, physical and mental rest is required. A concussion upsets the way the brain normally works and causes it to work longer and harder to complete even simple tasks. Activities that require concentration and focus may make symptoms worse and cause the brain to heal slower. Studies show that children’s brains take several weeks to heal following a concussion.

Returning to Daily Activities

  1. Be sure your child gets plenty of rest and enough sleep at night – no late nights. Keep the same bedtime weekdays and weekends.

  2. Encourage daytime naps or rest breaks when your child feels tired or worn-out.

  3. Limit your child’s activities that require a lot of thinking or concentration (including social

    activities, homework, video games, texting, computer, driving, jobrelated activities, movies,

    parties). These activities can slow the brain’s recovery.

  4. Limit your child’s physical activity, especially those activities where another injury or blow to the

    head may occur.

  5. Have your qualified health care professional check your child’s symptoms at different times to

Encourage your athlete to be honest with you, his/her coach and your health care provider about his/her symptoms. Many young athletes get caught up in the moment and/or feel pressured to return to sports before they are ready. It is better to miss practice or meets than the entire season... or risk permanent damage!


help guide recovery.


Returning to School

  1. Your athlete may need to initially return to school on a limited basis, for example for only half- days, at first. This should be done under the supervision of a qualified health care professional.

  2. Inform teacher(s), school counselor or administrator(s) about the injury and symptoms. School personnel should be instructed to watch for:

    1. Increased problems paying attention.

    2. Increased problems remembering or learning new information.

    3. Longer time needed to complete tasks or assignments.

    4. Greater irritability and decreased ability to cope with stress.

    5. Symptoms worsen (headache, tiredness) when doing schoolwork.

  3. Be sure your child takes multiple breaks during study time and watch for worsening of symptoms.

  4. If your child is still having concussion symptoms, he/she may need extra help with schoolrelated activities. As the symptoms decrease during recovery, the extra help can be removed gradually.

Returning to the Pool

  1. Returning to the pool is specific for each person. As an example, California law requires written permission from a health care provider before an athlete can return to play. Follow instructions and guidance provided by a health care professional. It is important that you, your child and your child’s coach follow these instructions carefully.

  2. Your child should NEVER be on deck, practice, or participate in competition if he/she still has ANY symptoms. (Be sure that your child does not have any symptoms at rest and while doing any physical activity and/or activities that require a lot of thinking or concentration).

  3. Be sure that the athletic trainer, coach and physical education teacher are aware of your child’injury and symptoms.

  4. Your athlete should complete a step-by-step exercise-based progression, under the direction of a qualified healthcare professional.


Insurance USA Swimming provides an excess accident medical insurance policy for USA Swimming members while participating or volunteering in a USA Swimming sponsored or sanctioned event. Details of the insurance coverage are on the USA Swimming website under Insurance and Risk Management.

Centers for Disease Control and Prevention

Zurich Concussion Conference (2012) Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.

ODH Violence and Injury Prevention Program National Federation of State High School Associations – Index concussions

and see “A parent’s guide to concussion in sports”.


Acknowledgment of Receipt of Concussion Information Sheet

Pursuant to California Health and Safety Code §124235, a concussion and head injury information sheet shall be given by each youth sports organization offering an athletic program to each athlete in that program. The information sheet shall be signed and returned by the athlete and, if the athlete is 17 years of age or younger, shall also be signed by the athlete’s parent or guardian before the athlete initiates practice or competition. The USA Swimming Concussion Information Sheet (three pages) is attached to this acknowledgment.

Please note, the information contained in the Swimming Concussion Information Sheet and this Acknowledgment is not medical advice and is no substitute for it.

I hereby acknowledge that I have received the USA Swimming Concussion Information Sheet (three pages) from Streamline Aquatics Club.  I have read and understand its contents.

I also acknowledge that if I have any questions regarding the signs or symptoms of a concussion or other head injuries, the need to seek medical attention and the protocol for returning to daily activities, school and the swimming pool, I will consult with a licensed health care provider.

_______________________ Athlete’s Name

__________________________ Parent’s or Guardian’s Name

_____________________________ __________ Athlete’s Signature/Date

_____________________________ __________ Parent’s or Guardian’s Signature/Date

This signed acknowledgment may be returned through an electronic medium, including but not limited to, fax or electronic mail. Please check with your USA Swimming Team representatives regarding contact information.