MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
105 CMR 201.00: Head Injuries and Concussions in Extracurricular Athletic Activities

YEAR END REPORTING FORM FOR SCHOOLS, 2016-2017

Please submit only one form per school.

105 CMR 201.00 requires that all public middle and high schools (including charter schools) serving grades 6 through 12 with extracurricular athletic activities, as well as all private schools that are members of the Massachusetts Interscholastic Athletic Association (MIAA), provide data to the Department of Public Health annually on the number of Report of Head Injury Forms received by the school and the number of those forms that indicate that the injury occurred during interscholastic athletics. This form provides the mechanism for complying with that regulation. The regulations specify that, unless school policies dictate otherwise, the Athletic Director is responsible for reporting these annual statistics to the Department of Public Health [105 CMR 201.012(C)(7)].

All counts should be for individual schools and for school year 2016-2017 only. If you are responsible for the reporting of more than one school, please fill out separate forms for each school. There is no limit on the number of forms that you will be able to submit.   

Thank you for completing this form and helping us to monitor the health and safety of our student athletes!

Any questions please contact Linda Brown at linda.brown@state.ma.us or 617-624-5432 or Laura Kersanske at laura.kersanske@state.ma.us or 617-624-5466.

All DPH required forms and information regarding sports concussion in school sports can be found at www.mass.gov/sportsconcussion.

*School District
For private schools, please select "PRIVATE" at the bottom of the menu. If your district does not appear in the list, please select "OTHER" at the bottom of the menu and enter the district in the box below.
*School Name
Schools are ordered by district (or by city/town if a private school).
If your school does not appear in the list, please select "OTHER" at the bottom of the menu and enter the school name in the box below.
*Grades Included in the School
Check all that apply.
*Is this an update to a form previously submitted for 2016-2017?
Required Reporting Information
*1) Please list the total number of "Report of Head Injury" forms received by this school in school year 2016-2017.
Please respond with numeric values only.
Report how many "Report of Head Injury" forms (or school-based equivalents) were received. This should include all head injuries and suspected concussions reported.  A school-based equivalent means a form that a school district or school develops in lieu of the Department of Public Health form which, at minimum, includes all of the information required by the Department's Report of Head Injury form.

*2) Please indicate whether "Report of Head Injury" forms are required to be submitted to this school only for students participating in extracurricular athletics/school sports or for all students.
Schools or school districts define their own policy on whether "Report of Head Injury" forms are required for all students or just for student athletes.
*3) Please list the number of "Report of Head Injury" forms received by this school in school year 2016-2017 indicating that the injury occurred when engaged in school sports.
Please respond with numeric values only.
Optional Reporting Information (This information is not required by regulation but can help inform policy and programming.)
4) Total number of Medical Clearance/Return to Play Forms this school received in school year 2016-2017.
Please respond with numeric values only.
Schools are required to utilize the Department of Public Health's Medical Clearance and Authorization form or school-based equivalent prior to a student returning to play.  This question asks schools to report how many Medical Clearance Forms (or school-based equivalents) were received.  Note that not every student is cleared to return to play in the same school year in which s/he is injured, so this total is not expected to equal the number of Report of Head Injury forms for student athletes.
5) Total School Enrollment
Please respond with numeric values only.
Please indicate the number of children attending this school. (This information can be obtained at http://profiles.doe.mass.edu/state_report/enrollmentbygrade.aspx)
6) Does your school have an extracurricular sports program?
An extracurricular sports program is defined as an organized school sponsored athletic activity generally occurring outside of school instructional hours under the direction of a coach, athletic director, or band leader.
7) Does your school have Licensed Athletic Trainers?
Licensed Athletic Trainer means any person who is licensed by the Board of Registration in Allied Health Professions in accordance with M.G.L. c. 112, § 23A and 259 CMR 4.00 as a professional athletic trainer and whose practice includes schools and extracurricular athletic activities. Pursuant to M.G.L. c. 112, § 23A, the athletic trainer practices under the direction of a physician duly registered in the Commonwealth.
8) How is the person who reviews the Pre-Participation Head Injury/Concussion Reporting Form receiving it?
9) Who reviews the Pre-Participation Head Injury/Concussion Reporting Form?
Please check all that apply.
10) How many people among the following groups completed a concussion-related annual training during school year 2016-2017?
Please respond with numeric values only.
Out of how many total school nurses?  
Out of how many total school physicians? 
Out of how many total coaches? 
Out of how many total athletic trainers? 
Out of how many total athletic directors? 
Out of how many total student athletes? 
If unknown, you can approximate.
Out of how many total parents? 
If unknown, you can approximate.
11) If there is any additional information collected by your school on student head injuries/concussions that you wish to provide, please provide below or upload.
You can upload your documents containing additional information here.

Allowed file type(s):