Fillable Returning SA Pre Particiption Screening 1 - ParentAthleteLetter

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Returning SA Pre Particiption Screening 1 - ParentAthleteLetter

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1
Cuesta College Athletic Training
PO Box 8106 (HWY 1), San Luis Obispo, CA 93403-8106
(805) 546-3225 ph. • (805) 546-3158 Fax
Dear Cuesta Student Athletes and Parents,
Cuesta Athletics abides by the medical policies set forth by the California Community College
Athletic Association Constitution and Bylaws (CCCAA). Cuesta participates in the Arch
Student and Intercollegiate Athletic Accident Insurance program. This program provides
secondary (or excess) coverage for injuries sustained while participating in practice or
play of intercollegiate athletics. This means that the student-athlete’s primary insurance will
be billed first in all cases and the remaining amount, if any, must be submitted to the
department’s secondary insurance for payment consideration. The department’s policy has a 52
week period of benefits from the date of the original injury.
In an effort to manage insurance and medical expenses, the Department of Athletics requires
that all student-athletes provide evidence of primary medical insurance before commencing
intercollegiate practice or play. Failure to provide evidence of insurance coverage may prevent
a student-athlete from participating in intercollegiate athletics’ activities. Please ensure that the
information on the attached questionnaire is completed accurately.
In the event that the individual is a member of a health maintenance organization, such as
Kaiser or Blue Shield HMO, we are required to send the athlete to their primary care physician
for treatment. We encourage student athletes to change their primary care physician to the San
Luis Obispo area in order to expedite the process should they become injured. This is also
beneficial for those athletes who have illnesses that the Student Health Center is not equipped
to handle. We hope you can understand that with ever-increasing medical costs we must utilize
all possible coverage for proper financial management and at the same time provide good
health care.
Listed below are the procedures each student athlete must follow should they become injured
during sport participation:
1. All injury evaluation and follow-up care must be done through the Athletic
Training Room (ATR).
2. When the athlete is seen inside the ATR the athletic trainer will write out an injury
report form. The athlete will then be given instructions for care of the injury. This
may include going to the Health Center or signing up to see one of the team
physicians during the clinic hours in the ATR.
3. If it has been determined that the student athlete will require treatment off campus, a
Student Insurance claim form must be filled out. This form must be completed by
the athlete, and by a Cuesta Athletic Trainer. Any athlete who seeks medical care
off campus for an athletically related injury without first consulting with the ATR
will not be covered by the Cuesta insurance.
4. If the athlete requires an off campus visit to a medical provider it must be
coordinated through the athlete’s primary insurance. This may mean calling for
2
authorization or visiting the primary care physician.
5. If the athlete or the athlete’s parents receive bills or explanation of benefits in the
mail, they must be forwarded to:
Student Insurance
10801 National Blvd, Suite 603
Los Angeles, CA 90064
If you do not have the itemized bills and explanation of benefits you cannot
proceed with payment from the Student Insurance Group.
6. Each injured athlete’s medical status will be reviewed with the respective head
coach on a regular basis to determine ability to participate.
I have enclosed a Medical History Questionnaire along with the Insurance Information sheet.
Please return these to the Athletic Training Room or Athletic Director. Remember that the
training room must have this information prior to any participation with your Cuesta Team.
I greatly appreciate your time and consideration in this matter. If you have any questions,
please call athletic training staff at (805) 546-3225.
Sincerely,
Cuesta Athletic Training Staff
3
CUESTA ATHLETIC TRAINING FACILITY GUIDELINES
1. You MUST take a shower before any type of treatment, evaluation, or use of the
whirlpools.
2. Sign in if you are receiving treatment (including ice, meds and equipment).
3. DO NOT remove any equipment or supplies from the Athletic Training Facility without
authorization and without signing out.
4. This is a co-ed Athletic Training Facility, proper attire is required.
5. Whirlpool
a. Attire for all: clean swim suit. NO SPANDEX.
b. No open wounds or blisters in whirlpool.
c. Bring your own towel.
d. Whirlpool temp should not be lower than 55°F.
e. Dry off before leaving whirlpool area.
6. Absolutely no eating or tobacco use in the Athletic Training Facility unless given
permission.
7. Keep cell phone use to a minimum and NEVER when talking to an athletic trainer or
physician. Use head phones for your music.
8. Athletic injuries must be evaluated by an Athletic Trainer prior to seeing a physician in
the Athletic Training Facility.
9. You must notify the Athletic Training Staff if you plan to seek medical attention for an
athletic injury outside of the Athletic Training Facility.
10. Please remember this is a medical facility and we ask that you treat it as such.
11. Refrain from any improper language, horseplay, or behavior that is unbecoming of a
Cuesta Student-Athlete.
Thank You,
Athletic Training Staff
4
5
Cuesta Intercollegiate Athletic
Insurance
Questionnaire
For Office
Use
Only
Ent
Comp
Ac
cident/Injury benefits for athletes are provided on an “excess” basis. This means ATHLETE’S OWN GROUP INSURANCE
OR THAT OF THE ATHLETE’S SPOUSE AND/OR PARENT MUST BE BILLED FIRST. Benefits are available from our program
only when the Athlete’s coverage is exhausted or does not apply. The following information is essential to assure that
expenses are adequately and completely covered by the proper insurance. Inadequate or incomplete answers will delay
payment of medical bills and may jeopardize the athlete’s credit rating. No medical expenses will be paid out of institutional
funds without a signed, accurate questionnaire on file. It is the athlete’s sole responsibility to keep the information contained in
this document current.
ATHLETES
INFORMATION ***WRITE CLEARLY; IF WE CAN’T READ IT, WE WON’T ACCEPT IT***
First Name MI Last Name SS# D.O.B.
Sport
Local Address
City State ZIP
Phone
Cell Phone
Student ID# Year
in
S
c
h
oo
l
:
SO
JU
DO YOU HAVE INSURANCE: YES NO
Please
list the Medical
Insurance Policies
You Have Below
Primary Insurance
Secondary Insurance
Subscriber’s Name Subscriber’s SS# Subscriber’s Name
Subscriber’s SS#
Employer
Insurance
Employer
Insurance
Insurance
Billing Address
Insurance Billing
Address
Insurance Group #
Claims Phone #
ID/Policy
#
Authorization
Phone
#
Insurance group #
Claims Phone#
ID/Policy
#
Authorization
Phone
#
Dental
Insurance
Coverage Vision
Insurance
Coverage
Dental Insurance
Dental Subscriber
Vision Insurance
Vision Subscriber
Dental
Policy
#
Dental
Phone
#
Vision
Policy
#
Vision
Phone
#
I/We
hereby certify that the foregoing
answers
are true, complete and correct to the
best
of
my/our
knowledge.
I/we
also hereby authorize any Insurance Company,
Organization, Employer, Hospital, Physician,
Surgeon, Pharmacy,
or other health
care
provider to
release
any information with
respect
to
injury,
treatment, or
insurance. A photo static copy of this authorization shall be considered
as
effective and valid
as
the
original.
Signature of Athlete Date
6
Cuesta College Athletic Training
PO Box 8106 (HWY 1), San Luis Obispo, CA 93403-8106
(805) 546-3225 ph. • (805) 546-3158 Fax
Returning Student-Athlete
Me
d
i
c
a
l
H
i
s
t
o
ry
Questionnaire
D
at
e
:
N
am
e
:
F
i
r
s
t
M
i
dd
l
e
Last
Age: Sex: M F
E
m
ai
l
A
dd
r
e
ss
:
Permanent
A
dd
r
es
s
(Other Than Local Address)
S
t
r
ee
t
:
P
h
o
n
e
#
( )
C
i
t
y
:
S
t
at
e
:
Z
i
p:
C
e
ll
#
(
)
Fat
h
er
/
G
u
ar
d
i
an
:
E
m
ai
l
:
S
t
r
ee
t
:
C
i
t
y
:
S
t
at
e
:
Z
i
p
:
H
o
m
e
P
h
o
n
e
#
(
)
Wo
r
k
P
h
o
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e
#
(
)
C
e
ll
P
h
o
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e
#
(
)
Mo
t
h
er
/
G
u
ar
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i
an
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E
m
ai
l
:
S
t
r
ee
t
:
C
i
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:
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t
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:
Z
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H
o
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P
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#
(
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P
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#
(
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C
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P
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#
(
)
Emergency
Contact
N
am
e
:
R
e
l
at
i
o
n
s
h
i
p:
H
o
m
e
P
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n
e
#
(
)
7
Returning Student-Athlete Annual Medical History Questionnaire
Shared Responsibility for Sport Safety
Participation in sports requires an acceptance to risk of injury. Athletes rightfully assume that
those who are responsible for the conducts of sport have taken responsible precautions to minimize the
risk of significant injury and that those participating in the sport will not intentionally inflict injury.
Periodic analysis of injury patterns continuously lead to refinements in the rules and other
safety guidelines. However, legislation of safety via the rule book and equipment standards, although
often necessary, is seldom effective by itself. To rely on officials to enforce compliance with the rule
book is as insufficient as to rely on warning labels to produce behavioral compliance with safety
guidelines. Compliance means respect on everyone’s part for the intent and purpose of a rule or
guideline, not merely technical satisfaction by some of its phrasing.
This annual form must be completed and returned before the student-athlete will be permitted to
practice or play. The California Community College Athletic Association (CCCAA) policies
recommend that all student-athletes have qualifying medical evaluations upon their initial entrance into
an institution’s intercollegiate athletic program. Subsequent to the initial medical evaluation, an
updated medical history should be performed annually. Further pre-participation physical examinations
are not believed to be necessary unless warranted by the updated history. Cuesta College, San Luis
Obispo supports and adheres to this CCCAA policy. Further medical evaluations subsequent to the
initial qualifying examination) may be required in specific cases.
Dat
e
of In
i
t
ial
P
hys
ical
E
xam
i
nat
i
on:
1. Have you been hospitalized or had a major illness since the initial physical
examination? If yes: __________________________________
2. Are you currently ill in any way? If yes:
3. Have you had a major injury since the initial physical examination? If
yes:
4. Do you currently have any incompletely healed injuries? If yes:
Select One
YES NO
YES NO
YES NO
YES NO
5. Are you taking any medication on a regular or continuing basis? If yes:
YES NO
6. Are you currently taking any short-course medication for a specific
current injury or illness? If yes:
7. Have you had any operations or surgeries since the completion of the
Spring semester? If yes:
8. Have you had any accidents and/or other trauma since the completion of
Spring semester? If yes:
9. Have you seen a physician for any reason since the completion of Spring
semester? If yes:
10. Do you believe there is any health reason why you should not participate
in the Cuesta Intercollegiate Athletic Program at this time? If yes:
YES NO
YES NO
YES NO
YES NO
YES NO
8
The undersigned, herewith:
A. Understands that he or she must refrain from practice while ill or injured, whether
or not receiving medical treatment until he or she is discharged from treatment or
is
given permission by the clinical practitioner to restart participation despite
continuing treatment.
B. Understands that having passed the physical examination does not necessarily
mean that he or she is physically qualified to engage in athletics, but only that the
evaluator did not find a medical reason to disqualify him or her at the time of the
examination.
C. Understands and will abide by the Athletic Training Facility Guidelines.
D. Certifies that the answers to the above questions are correct and true.
Date:
Signature
of
Student-
A
thlete:
Physician’s
Evaluation
If you have suffered a serious injury or illness in the last 12 months, where you
missed multiple competitions or practice. You must complete the following
physical or have a clearance to return to participation from your treating
physician on file in the athletic training
room
.
No clearance
Cleared for return to participation with no restrictions.
Cleared for return to participate with restrictions, conditions, or special
instructions as follows:
Physician’s
Signature
M.D.
Date:
TO BE COMPLETED BY CUESTA ATHLETIC TRAINING STAFF
This form has been reviewed by the athletic training staff.
[ ] Athlete needs to be referred for an evaluation of the following condition(s) by a
physician:
Referred to M.D.
Physician
A
.T.C.
Date:
Signature of NATA
Certified
A
thletic
Trainer
9
Cuesta College Athletic Training
PO Box 8106 (HWY 1), San Luis Obispo, CA 93403-8106
(805) 546-3225 ph. • (805) 546-3158 Fax
Directions:
Medical Consent
I. Please read carefully and sign the following consent forms. If you are
under 18 years of age, your parents must also sign.
II. If you choose to refuse to sign any of these consent forms, please write
“Refuse to Sign”, the date, and your signature. Notify your athletic
trainer.
III. This document will remain in effect for one year of signing and any
portion may be revoked at the discretion of the student-athlete by
notifying your athletic trainer.
Basic Content:
I. I Medical Consent
: Allows athletic trainers and physicians to treat any
injury or illness you sustain while an athlete at Cuesta College, San Luis
Obispo.
II. Release of Information to the Media: Allows those listed to release
information concerning your injuries to the media.
III. Release of Information to Professional Sports: Allows those listed to
release any and all information concerning you, including medical
records and other items listed.
IV. Assumption of Risk: Acknowledges that all athletic activity affords a
certain amount of risk of injury and that you are aware of these risks and
the rules of your sport intended to minimize these risks.
V. Blood Borne Pathogens: Acknowledges that exposure and transmission
of Blood Borne Pathogens is possible through athletics and that you are
willing to assume responsibility.
I. Medical Consent
I hereby grant permission to the Cuesta College, San Luis Obispo team
physician and/or their consulting physician to render to my son or daughter
or myself any treatment or medical or surgical care that they deem reasonably
necessary to the health and well being of the student-athlete.
10
I also hereby authorize the athletic training staff at Cuesta College, San Luis
Obispo who are under the guidance of the team physician, to render to my
son or daughter or myself any preventative, first aid, rehabilitative or
emergency treatment that they deem reasonably necessary to the health and
well being of the student-athlete.
Also, when necessary for executing such case, I grant permission for
hospitalization at an accredited hospital.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Signature of Student-Athlete
Date:
Signature of Parent or Guardian
II. Authorization for release of Medical Information to the Media
This is to authorize Cuesta College, San Luis Obispo athletic training staff
and team physicians to release medical information of my son or daughter or
myself to the Cuesta Sports Information Department to provide media
outlets for any information concerning illness or injury relative to my past,
present, or future participation in intercollegiate athletics at Cuesta.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Signature of Student-Athlete
Date:
Signature of Parent or Guardian
11
III. Authorization for Release of Medical Information for Employment in
Professional Sports
I, , hereby authorize and request the Cuesta
College San Luis Obispo Athletic Training Department to supply to
professional athletic teams, their scouts, representative agents, athletic trainers,
physicians, or employees, any and all medical information concerning or
having bearing upon my participation in intercollegiate athletics at Cuesta
College, San Luis Obispo. This authorization shall include, but not limited, to
any and all information within their knowledge, or contained in any medical
records under their supervision or control concerning my physical condition,
illness, injuries, and any treatment, hospitalization, examinations, x-rays, and
to make such reports to such persons or organizations concerning myself that
they may request; and I hereby fully discharge all parties to whom this
authorization extends from any and all privilege in connection with the
disclosure of information included in this authorization.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Signature of Student-Athlete
Date:
Signature of Parent or Guardian
IV. Assumption of Risk
Participation in sport requires an acceptance of risk of injury. Athletes
rightfully assume that those who are responsible for the conduct of sport
have taken reasonable precaution to minimize such risk and that peers
participating in the sport will not intentionally inflict injury upon them.
Attempts to legislate safety via rule books and equipment standards,
while helpful, is seldom entirely effective. Relying on officials to enforce
compliance with rules is also insufficient. Compliance with rules implies
respect on everyone’s part (student-athlete, coach, athletic trainer,
physician, and athletic director) for the intent and purpose of rules and
guidelines.
12
I understand that by voluntarily participating in athletics at the collegiate
level, I am undertaking a non-controllable risk, which may result in injury,
illness or death.
I understand sickness and/or injuries are common in all athletics and that
Cuesta College, San Luis Obispo Athletics Department will provide the most
reasonable medical coverage in order to reduce the severity of such illness
and/or injury. The administration, coaches, and athletic trainers will equally
provide to each student-athlete, equipment required to produce the safest
possible intercollegiate athletic environment regardless of age, sex, race, or
religion.
I acknowledge and understand that the college is not providing transportation
and it is my responsibility to arrange for any transportation to and from the
activity. If the college is providing transportation but I do not use the
transportation, I am responsible to make my own transportation
arrangements and the college assumes no responsibility or liability of any
kind.
I have read the above assumption of risk statement. I understand that there
are certain inherent risks involved while participating in intercollegiate
athletics. I acknowledge the fact these risks exist and I am willing to assume
responsibility for such risks while participating at Cuesta College, San Luis
Obispo.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Signature of Student-Athlete
Date:
Signature of Parent or Guardian
13
V. Blood-Borne Pathogens and Intercollegiate Athletics
(Copyright, 1997, by the NCAA)
Blood-Borne pathogens are disease-causing microorganisms that can
be potentially transmitted through blood contact. The blood-borne
pathogens of concern include (but not limited to) the hepatitis virus
(HBV) and the human immunodeficiency virus (HIV). Infection with
these viruses has increased throughout the last decade among all
portions of the general population. These diseases have potential for
catastrophic health consequences. Knowledge and aware
ness of
appropriate preventative strategies are essential for all members of
society, including student- athlete.
The particular blood-borne pathogens HBV and HIV are transmitted by
practicing risky unprotected sexual contact (heterosexual and
homosexual), direct contact with infected blood or blood components,
and prenatally from mother to baby. Experts have concurred that the risk
of transmission on the athletic field is minimal.
HBV is a blood-borne pathogen that can cause infection of the liver.
Many of those infected will range from no symptoms to a mild flu-like
illness. One third will have severe hepatitis, which cause the death of one
percent of that group. Currently, in the United States there are one
million chronic carriers of HBV. Chronic complications of HBV infections
include cirrhosis of the liver and liver cancer. The incidence of HBV in
student-athletes is presumably low, but those practicing risky behaviors
off the athletic field have an increased likelihood of infection (just as in
the case of HIV). An effective vaccine to prevent HBV is available and
recommended for all college students by the American College Health
Association.
The Acquired Immunodeficiency Syndrome (AIDS) is caused by HIV,
which infects cells of the immune system and other tissues such as the
brain. Some of those infected will remain asymptomatic for many years.
14
Others will more rapidly develop the manifestation of the HIV disease
(i.e. AIDS). Some experts believe virtually all persons infected with HIV
will eventually develop AIDS, which is fatal. In the United States there
are 40,000 to 50,000 newly infected persons each year. There are 1.5
million infected persons in the United States. The risk of infection is
increased by having unprotected sexual intercourse and sharing IV
needles. Currently, there is no vaccination available to prevent HIV.
HBV is a more “sturdy/durable” virus than HIV and is more highly
concentrated in blood. HBV is more likely to be transmitted by exposure
to infected blood, particularly with needle-stick exposure, but also
exposure to open wounds and mucus membranes. The risk of
transmission for either HBV or HIV is considered minimal; however,
most experts agree that the specific epidemiological and biologic
characteristics of the viruses make them a realistic concern for
transmission in sports with sustained close physical contact.
Cuesta College, San Luis Obispo athletic training staff acknowledges the
risks and utilizes Universal Precautions as recommended by the Center
for Disease Control, OSHA and the NCAA Sports Medicine Handbook to
minimize the risk of blood-borne pathogen exposure and transmission on
the context of athletic events and treatment guidelines for the health care
of student-athletes.
I have carefully read and fully understand the risk of blood-borne
pathogens exposure and transmission.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Signature of Student-Athlete
Date:
Signature of Parent or Guardian
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Returning SA Pre Particiption Screening 1 - ParentAthleteLetter

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Completed 11 March 2020

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