INFORMATION AND CONSENT
PLAYER / PARENTS (on behalf of minor):
ImPACT™ (Immediate Post Concussion Assessment and Cognitive Testing)
Thank you for your interest in taking ImPACT™, part of an innovative Concussion Safety Program provided through SportConcussions.com and Hisey Consulting Group Inc.
ImPACT is a software tool designed to assist clinicians (i.e. neuropsychologists or doctors who have been trained on using this tool) in evaluating and treating sports-related head injuries. It consists of a group of computerized tests that are sensitive to the effects of concussion. You will be asked to answer a number of questions and take tests such as your memory, concentration and reaction time that measure how your brain is functioning. The entire evaluation takes approximately 30 minutes to complete and poses no risk to you.
ImPACT testing is completed at two different times: first as a pre-injury “baseline” test and, if a concussion is suspected, then as a post-injury test.
ImPACT Baseline Test
The baseline assessment is administered before an injury has occurred to establish how you perform in your typical state of health. Your baseline test will serve as a comparison point for future testing in the event that you sustain a sports-related concussion. This comparison will assist your physician in determining the best approach to treating your injury and when it is safest to return to sports.
Arrangements will be made to complete baseline testing in a quiet environment, possibly in small groups, that is free from distraction in order to achieve the most accurate results. Minors should be actively supervised by a responsible adult during the baseline testing process to ensure that this environment is maintained throughout the duration of the baseline test.
When an injury occurs resulting in possible concussion, post-injury ImPACT testing should be completed. This testing involves questions regarding the nature of the injury, accompanying physical symptoms as well as tests relating to how your brain is functioning. The data from the post-injury test will then be compared to your individual baseline test results in order to assess the nature of the injury.
Unlike baseline testing, post-injury testing will always be completed on an individual basis within the office of a trained and credentialed ImPACT Doctor or Neuropsychologist. These clinicians are able to accurately assess these test results in conjunction with their clinical examination in order to develop an appropriate treatment plan.
Privacy and Security
In order to use the ImPACT tool, we need to collect personal information about you, such as your name, telephone number, address, and payment information (for example, credit card information or information relating to an Internet payment service like PayPal™).
When you are completing ImPACT baseline or post-injury testing, we will also collect personal health information as part of the testing protocol, such as your weight, height, current and past treatments and medications, symptoms and health history.
All of the personal information which you provide, including personal health information, is treated in a strictly confidential manner. Test data is stored in a segregated database on ImPACT’s secure server in the United States, which is protected by firewalls and security measures and is compliant with Canadian privacy laws. For more information about ImPACT’s privacy policies, please see ImPACT’s website at ImPACT Applications, Inc.
Access to your testing results is fully encrypted. If you have any questions regarding your ImPACT test results or our privacy practices please contact Don Hisey email@example.com.
The results of your baseline and post-injury testing results will be accessible to Sportconcussions.com and may be shared with accredited clinicians with whom you consult after an injury to ensure that you (or your son or daughter) recieve the best possible care in a timely fashion. Hisey Consulting Group Inc. and Sportconcussions.com maintains a list of health professionals in various locations who are qualified to interpret ImPACT test results and who may be given access to your test results should you choose to consult with them.
ImPACT test results should only be interpreted by qualified healthcare professional such as a neuropsychologist or physician who has received training in interpreting these tests. Any use by a non-qualified individual could lead to misinterpretation, which could result in an incorrect diagnosis or treatment (or non-treatment) and lead to future negative consequences.
No medical test is 100% accurate and ImPACT is designed to be used in conjunction with other medical findings, facts, records and test results that may be ordered by your physician. It should be used as a part of an overall diagnosis/treatment program for sports concussions. ImPACT test results are important but not sufficient to either rule in or rule out a concussion. Completing baseline testing does not constitute a doctor-patient relationship with any member of SportConcussions.com or Hisey Consulting Group Inc; Hisey Consulting Group Inc. and Sportconcussions.com are not responsible for any clinical decision making related to the interpretation of the test results. Any health records relating to the interpretation of baseline or post-injury test results or any clinical investigations or findings will need to be obtained directly from the responsible health professional.
I understand that my consent may be revoked at any time by contacting Hisey Consulting Group in writing at Box 428, Ilderton, Ontario, N0M 2A0 or by email firstname.lastname@example.org.
YOU MUST HAVE THE PROPER CLINIC CODE BEFORE
PROCEEDING - contact Dr. Czarnota (email@example.com) or Don Hisey (firstname.lastname@example.org) if
you do not have the code or did not received the code from your