Susquehanna University



STUDENT HEALTH REPORTING FORMHealth Center620 University Avenue, Selinsgrove, PA 17870-1001Phone (570) 374-9164 / Fax (570) 372-2729Health Center Webpage – Counseling Center - Phone (570) 372-4751 / Fax (570) 372-2776Athletic Department - Phone (570) 372-4270 / Fax (570) 372-2758Information you provide will not be used to influence your situation at the university; it will be used solely as an aid to provide health care while you are a student. In the future, medical information shared with the Health Center would be strictly for the use of the Health Center; sharing of medical information will be governed by the enclosed HIPAA regulations. The above-named offices would not share future information without the consent of the student.Must be returned to the Health Center before July 15 or a hold will be placed on your registration, athletic participation, and/or your room key will be held.SECTIONS I, II, and III TO BE COMPLETED BY STUDENT (PLEASE PRINT NEATLY IN BLACK INK)Part I – PERSONAL DATAName: Last First MiddleDate of Birth:// Social Security No.: - - Month Day YearSemester you are entering (circle): Fall SpringClass you are entering (circle): FR SO JR SRPreviously enrolled at Susquehanna University (circle): No Yes If Yes, year(s) enrolled:Sport(s) you plan on participating in at Susquehanna University:Female Male Transgender Marital Status: Citizenship: Religion:Home Address: No. & Street City/Town State ZipBirth State: Country of Origin if other than United States:Home Phone: Student’s Cellular Phone:In case of an emergency notify: Name Relationship Home Phone Home Address Cellular Phone Business PhoneFamily Physician: Phone:Address:Part II – FAMILY AND PERSONAL HISTORYDo you have any known allergies? If so, please list:YesNoSpecify Allergy: Epi Pen:YesNoDrug Food Insect Sting/Bite OtherHas any person, related by blood, had any of the following:YesNoRelationshipAlcohol/Drug ProblemsBlood or Clotting DisorderCholesterol or Blood Fat DisorderDiabetesGlaucomaHeart Attack Before Age 55High Blood PressurePsychiatric IllnessStrokeYesNoRelationshipCancer – Specify Type:Has any member of your family died suddenly under the age of 50? If yes, cause of death:______________________________SuicideOther – Specify:Have you ever had or do you now have: (please check at right of each item and if “yes”, indicate year of first occurrence)YesNoYearAbdominal – Specify: Appendicitis Bleeding from Rectum Hernia Injury to Kidney Injury to Spleen Stomach Trouble – Specify:Allergy Injection TherapyAsthmaBlood Pressure Issues – Specify High / Low:Blood Problems – Specify: Anemia Sickle Cell Anemia Sickle Cell Trait TransfusionCancer – Specify:Chicken PoxCysts or Lumps – Specify:Dermatology (Skin Disorder) – Specify:DiabetesEar, Nose, Throat Problems – Specify:Epilepsy / SeizuresEye Problems – Specify:Frequent HeadachesGall Bladder Trouble or GallstonesHead Problems – Specify:Heart Problems – Specify: Syncopal Episode Chest Pain Dizziness Extra Heart Beat Heart Murmur Rheumatic Fever Other – Specify:YesNoYearHearing LossHypoglycemiaInfectious MononucleosisJaundice or HepatitisMalariaNeurological Issues – Specify: Head Injury – Specify: Concussion – Specify: Fracture – Specify: Unconsciousness – Specify Other – Specify: Neck Injury – Specify: Fracture – Specify: Pinched Nerve – Specify: Other – Specify:Orthopedic Problems – Specify: Ankle – Specify: Arm / Elbow / Wrist / Hand/Fingers – Specify: Back/Ribs – Specify: Foot – Specify: Hip / Groin – Specify: Knee – Specify: Lower Leg – Specify: Shoulder – Specify: Thigh – Specify: Other (Stress Fracture, Etc.) – Specify:ParalysisPersonal TraumaPilonidal CystSexually Transmitted Disease – Specify:Smoke - Number of Cigarettes a Day:______Thyroid Problems – Specify:TuberculosisUrinary / Kidney Problems – Specify:Other health problems including hospitalizations or surgical operations – Specify:Have you ever had episodes of unexplained shortness of breath, wheezing or chest pain? – Specify:Are you taking any medications routinely? – Specify:Please mark “YES” if any organs are NOT intact – Specify: Eyes Kidneys Lungs Testes (Ovaries / Testicles) Other – Specify:If there is other medical history important to your safety or to the safety of others, please report it below:THIS SECTION TO BE COMPLETED BY FEMALES ONLY:Have you ever had any gynecological / obstetrics issues? – Specify:Are you pregnant?Menstrual Disorder – Specify:Part III – MENTAL HEALTH/SOCIAL HISTORYPlease note that mental health, like all of your health information, is confidential. The Health Center and the Counseling Center are separate departments. In the future, a consent signed by the student will be obtained before sharing any additional health information. If you wish to discuss mental health issues with a counselor or coordinate an appointment, please call the Counseling Center at 570-372-4751. Have you ever had or do you now have: (Please check at right of each item and if “Yes”, indicate year of first occurrence.”)YesNoYearDepressionAnxietyBipolar disorderEating disorderAlcohol / drug abuse or dependenceOther mental health concerns – Specify:Please indicate if you have had the following experiences: YesNoYearAttended counseling for mental health concernsTaken a prescribed medication for mental health concernsBeen hospitalized for eating disorder / mental health concernsReceived treatment for alcohol or drug abusePart IV and V - To be completed by a health care providerMust be returned to the Health Center before July 15or a hold will be placed on your registration, athletic participation and/or your room key will be held.Part IV – REPORT OF PHYSICAL EXAMINATIONPhysical MUST be completed within six months prior to the first day of classes, which begin August 31, 2015.Name: Last First MiddleDate of Entry to SU: Date of Birth: Social Security No.: - -Date of Physical: (Must be completed within six months prior to the first day of classes on August 31, 2015.)Temperature: Pulse: Respiration:Height: Weight: BP:Are there abnormalities of the following systems? Please describe fully.SystemYesNoComments 1. Head, Ears, Nose or Throat 2. Respiratory 3. Cardiovascular 4. Gastrointestinal 5. Hernia 6. Eyes 7. Genitourinary 8. Musculoskeletal 9. Metabolic / Endocrine10. Neuropsychiatric11. SkinIs there loss or seriously impaired function of any organ? No Yes Explain:Recommendations for physical activity: Unlimited Limited Explain:Athlete’s clearance for full physical activity (please check one): GrantedGranted with restrictions Specify:Postponed untilRejectedReason:Other Recommendations:Orthopedic screening findings or comments:Has the patient ever been treated for an eating disorder? No Yes Explain:Has the student ever been treated for any other mental health condition? No Yes Explain:Is the student currently under treatment or had treatment within the past year for any medical or mental health condition? No Yes Explain:Continue to next page…….Do you have documentation of a sickle cell trait test? No _______ Yes ________ Results: Positive_______ Negative________Unknown_________Do you have any recommendations regarding the care of this student? No Yes Explain:How long have you known this student? Do you have any general comments?If you have any additional recommendations, please feel free to include a note or letter with this health record.*************************************************************************************************************************************************************************************************************************************************MUST BE SIGNED BY HEALTH CARE PROVIDER:Health Care Provider’s Name Printed: Health Care Provider’s Signature: Date:Address: Phone: ( ) Fax: ( )Part V – IMMUNIZATION RECORDTo be completed and signed by a health care provider - Dates must include month(M), day(D) (if available) and year(Y). All information, including dates, must be placed on the SU form and must be in English.The following immunizations are for your protection as well as that of the University community.Must be returned to the Health Center before July 15 or a hold will be placed on your registration, athletic participation and/or your room key will be held. If you have problems obtaining your immunizations, contact your local Department of Health or high school for possible assistance.Section IThe following immunizations are recommended but not requiredA. Human Papillomavirus Vaccine (HPV2 or HPV4) (Three doses of vaccine for female and male college students 11-26 years of age at 0, 2 and 6 month intervals.) Immunization (indicate which preparation) Quadrivalent (HPV4) or Bivalent (HPV2) a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / M D Y M D Y M D YB. Hepatitis A 1. Immunization (hepatitis A) a. Dose #1 / / b. Dose #2 / / M D Y M D Y 2. Immunization (combined hepatitis A and B vaccine) a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / M D Y M D Y M D Y C. Serogroup B Meningococcal Vaccines (MenB) 1. MenB (Bexsero?, Novartis) a. Dose #1 / / b. Dose #2 / / M D Y M D Y OR (either 1 or 2) 2. MenB (Trumenba?, Pfizer)a. Dose #1 / / b. Dose #2 / / M D Y M D Y Note:? Use of brand names is not meant to preclude the use of other meningococcal vaccines where appropriate.Continue to next page…….Section IIThe following are REQUIRED immunizations.A. MMR (Measles, Mumps, Rubella) – Two doses required at least 28 days apart for students born after 1956 and all health sciences students. 1. Dose 1 given at age 12-15 months or later……………………………………………………….…………….#1 / / M D Y 2. Dose 2 given at age 4-6 years or later, and at least 28 days after first dose…………...…..……………....#2 / / M D YB. Tetanus, Diphtheria, Pertussis – Primary series with DtaP or DTP and booster with Tdap in the past 10 years meets requirements. 1. Primary series completed? Yes No Date of last dose in series: / / M D Y 2. Date of most recent booster dose: / / M D Y Type of booster: Td Tdap Tdap booster recommended for ages 11-64 unless contraindicated.C. Hepatitis B - Three doses of vaccine or two doses of adult vaccine or a positive hepatitis B surface antibody meets the requirement. 1. Immunization (hepatitis B) a. Dose #1 / / b. Dose #2 / / c. Dose #3 / / M D Y M D Y M D Y 2. Hepatitis B surface antibody: Date / / Result: Reactive Non-reactive M D YD. Meningococcal – (A, C, Y, W-135) One or two doses for all college students. This is required for all students residing in a residence hall. A second dose is required if primary dose was administered before 16th birthday. 1. Quadrivalent conjugate a. Dose #1 / / b. Dose #2 / / M D Y M D Y 2. Quadrivalent polysaccharide (acceptable alternative if conjugate not available) Date / / M D Y E. Varicella – History of chicken pox, positive varicella antibody or 2 doses of vaccine meet requirements. 1. History of Disease: Yes No 2. Varicella antibody: // Result: Reactive Non-reactive M D Y 3. Immunization: a. Dose #1……………………..………………..…………………………………………….……….#1 / / M D Y b. Dose #2 – Given at least 12 weeks after first dose ages 1-12 years and at least 4 weeks after first dose if age 13 years or older………....…………………………………………………………………...…….…………….#2 / / M D YF. Polio – Primary series, doses at least 28 days apart. Three primary series schedules are acceptable. 1. OPV alone (oral Sabin three doses): #1 / / #2 / / #3 / / . M D Y M D Y M D Y 2. IPV alone (injected Salk four doses): #1 / / #2 / / #3 / / #4 / / M D Y M D Y M D Y M D Y Continue to next page…….G. PART I: Tuberculosis (TB) Screening Questionnaire (to be completed by incoming students)Please answer the following questions: Have you ever had close contact with persons known or suspected to have active TB disease? □ Yes □ No Were you born in one of the countries listed below that have a high incidence of active TB disease? □ Yes □ No (If yes, please CIRCLE the country, below) Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia CambodiaCameroon Central African Republic Chad China Colombia Comoros Congo C?te d'Ivoire Democratic People's Republic of Korea Democratic Republic of the Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Gabon Gambia Georgia Ghana Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iran (Islamic Republic of)Iraq Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lesotho Liberia Libya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius MexicoMicronesia (Federated States of) Mongolia Morocco Mozambique Myanmar Namibia NauruNepal Nicaragua Niger Nigeria NiuePakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Vincent and the Grenadines Sao Tome and Principe Senegal SerbiaSeychelles Sierra Leone Singapore Solomon Islands Somalia South Africa South SudanSri Lanka Sudan Suriname Swaziland Tajikistan Thailand Timor-Leste Togo Trinidad and TobagoTunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia ZimbabweSource: Supplement – 2012 TB Incidence Rate UpdatedHave you had frequent or prolonged visits* to one or more of the countries listed above with a high □ Yes □ No prevalence of TB disease? (If yes, CHECK the countries) Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, □ Yes □ No long-term care facilities and homeless shelters)? Have you been a volunteer or health-care worker who served clients who are at increased risk for active □ Yes □ No TB disease? Have you ever been a member of any of the following groups that may have an increased incidence of □ Yes □ No latent M. tuberculosis infection or active TB disease – medically underserved, low-income or abusing drugs or alcohol? If the answer is YES to any of the above questions, Susquehanna University requires that you receive TB testing as soon as possible but at least prior to the start of the subsequent semester. IMPORTANT NOTE: If the answer to all of the above questions is NO (PLEASE STOP HERE – SKIP PART II AND PART III), no further testing or further action is required. * The significance of the travel exposure should be discussed with a health care provider and evaluated. PART II: Clinical Assessment by Health Care Provider (only complete this section if answered YES to any PART I question)Clinicians should review and verify the information in Part I. Persons answering YES to any of the questions in Part I are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), unless a previous positive test has been documented. History of a positive TB skin test or IGRA blood test? (If yes, document below.) □ Yes □ No History of BCG vaccination? (If yes, consider IGRA if possible.) □ Yes □ No Continue to next page…….1. TB Symptom Check - (only complete this section if answered YES to any PART I question)Does the student have signs or symptoms of active pulmonary tuberculosis disease? □ Yes □ No If No, proceed to either step 2 or step 3 below. If yes, check all that apply below:□ Cough (especially if lasting for 3 weeks or longer) with or without sputum production □ Coughing up blood (hemoptysis) □ Chest pain □ Loss of appetite □ Unexplained weight loss □ Night sweats □ Fever Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray and sputum evaluation as indicated. 2. Tuberculin Skin Test (TST) - (only complete this section if answered YES to any PART I question)(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, write “0”. The TST interpretation should be based on mm of induration as well as risk factors.)** Date Given: / / Date Read:// M D Y M D YResult: mm of induration **Interpretation: positive negativeDate Given: / / Date Read:// M D Y M D YResult: mm of induration **Interpretation: positive negative**Interpretation guidelines:**Interpretation guidelines >5 mm is positive: Recent close contacts of an individual with infectious TB persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for >1 month.) HIV-infected persons >10 mm is positive:recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of time injection drug users mycobacteriology laboratory personnel residents, employees, or volunteers in high-risk congregate settings persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renal failure, certain types of cancer (leukemias and lymphomas, cancers of the head, neck or lung), gastrectomy or jejunoileal bypass and weight loss of at least 10% below ideal body weight.>15 mm is positive: persons with no known risk factors for TB who, except for certain testing programs required by law or regulation, would otherwise not be tested. * The significance of the travel exposure should be discussed with a health care provider and evaluated. 3. Interferon Gamma Release Assay (IGRA) - (only complete this section if answered YES to any PART I question)Date Obtained: / / (specify method) QFT-GIT T-Spot other M D Y Result: negative positive indeterminate borderline (T-Spot only) Date Obtained: / / (specify method) QFT-GIT T-Spot other M D Y Result: negative positive indeterminate borderline (T-Spot only) 4. Chest x-ray: (Required if TST or IGRA is positive) - (only complete this section if answered YES to any PART I question)Date of chest x-ray: / / Result: normal abnormal M D Y Continue to next page……. PART III: Management of Positive TST or IGRA - (only complete this section if answered YES to any PART I question)All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a recommendation to be treated for latent TB with appropriate medication. However, students in the following groups are at increased risk of progression from LTBI to TB disease and should be prioritized to begin treatment as soon as possible. Infected with HIV Recently infected with M. tuberculosis (within the past 2 years) History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph consistent with prior TB disease Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic corticosteroids equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy following organ transplantation Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia or cancer of the head, neck or lung Have had a gastrectomy or jejunoileal bypass Weigh less than 90% of their ideal body weight Cigarette smokers and persons who abuse drugs and/or alcohol**Populations defined locally as having an increased incidence of disease due to M. tuberculosis, including medically underserved, low-income populations ______Student agrees to receive treatment ______Student declines treatment at this time *************************************************************************************************************************************************************************************************************************************************MUST BE SIGNED BY HEALTH CARE PROVIDER:Please place additional physician recommendations or comments on a separate paper. This information will be secured with your health record.Health Care Provider’s Name Printed: Health Care Provider’s Signature: Date:Address: Phone: ( ) Fax: ( )ALLERGY INJECTIONSIMPORTANT NOTE: The SU Allergy Injection Policy must be printed and requires a signature from your allergist.The Susquehanna University Student Health Center offers an allergy injection service for students receiving immunotherapy ordered by their private allergist. Registered nurses are available to administer injections, coordinate care within the student health clinic, and consult your allergist as needed.Allergy injection students must be currently under the care of an allergist. A minimum of an annual visit to your private allergist is required. If you are starting the first vial of any allergy injection, you must receive the first dose from your allergist. SU nursing staff will NOT administer the first dose of any new allergy vial.Please go to (located under the “Forms” link) to print out a copy of the Susquehanna University Allergy Injection Policy. Once you have reviewed this policy, take the policy to your allergist for approval. A signature is required from your allergist. The Health Center cannot administer injections without this completed form.Part VI – HEALTH INSURANCE INFORMATIONIMPORTANT NOTE: Before arriving on campus, PLEASE PHONE YOUR HEALTH INSURANCE COMPANY to inform them that your student will be attending college and may be “out of network.” Discuss the restrictions and provisions that your primary insurance can offer your student in Selinsgrove, Pennsylvania. Please ask if Geisinger Health Systems participates with your insurance.With your health record, please INCLUDE A COPY OF YOUR INSURANCE CARD AND PRESCRIPTION CARD and make sure you have a copy to carry with you to all your appointments. PRIMARY INSURANCE INFORMATION:Primary Insurance Company Name: Insurance Company Address Insurance Company Phone Number Effective Date Identification Number Policy Number Group Number Co-Pay: $ $ $ Plan Plan Code Product Name Office Visit Specialty ERPolicy Subscriber’s Information: Subscriber’s Name (as appears on card) Subscriber’s Date of Birth Subscriber’s GenderStudent Relationship to Subscriber Employer Employer’s Phone Number(ie: child, spouse, etc)SECONDARY INSURANCE INFORMATION (If Applicable):Secondary Insurance Company Name: Insurance Company Address Insurance Company Phone Number Effective Date Identification Number Policy Number Group Number Co-Pay: $ $ $ Plan Plan Code Product Name Office Visit Specialty ERPolicy Subscriber’s Information: Subscriber’s Name (as appears on card) Subscriber’s Date of Birth Subscriber’s GenderStudent Relationship to Subscriber Employer Employer’s Phone Number(ie: child, spouse, etc)PRESCRIPTION COVERAGE INFORMATION:Do you have a prescription plan? No Yes If yes, what is your co-pay?Name of prescription plan/company: Group No.:A mandatory Health Center fee will be applied to your tuition, allowing no co-payment when students visit the Susquehanna University Health Center for illness or injury. Additionally, most lab services are covered by this “in excess” benefit package, within limits. In cases where charges exceed the plan limit, claims will be submitted to the student’s primary insurance first. To find more information about this benefit package, please visit the following web page: VII – NOTICE OF PRIVACY PRACTICESThis section of Part VII to be completed by ALL STUDENTSThis section pertains to the enclosed Notice of Privacy Practices which pertains to the Health Center’s uses and disclosures of your medical information. IMPORTANT NOTE: The Susquehanna University Health Center is located adjacent to the Geisinger-Susquehanna University Facility. With the student’s consent, records will be shared with this facility, as needed, for referrals.ACKNOWLEDGEMENT OF INFORMATION PRACTICESAs part of my health care, the Health Center creates and stores information about me. This includes records concerning my health history, symptoms, examinations, test results and plans for future care.I understand that this information serves as a basis for my continuing care.I understand that this information is used as a means of communication among the Health Center personnel and with medical personnel outside of this practice.I understand that this information serves as a source of information for applying my diagnoses and surgical information for billing purposes.I understand that this information is a way for third-party insurance companies to assure that a service that was billed for was actually performed.I understand that this information can be used as a tool to assess the quality of care provided to patients.I have been provided an opportunity to review the Notice of Privacy Practices for the Health Center that provides a more complete review of information uses and disclosures.I understand that I have the right to review this Notice of Privacy Practices before signing this consent.I understand that the Health Center may change their information practices at any time and that a current copy will be available for my inspection during regular business hours.Student’s Signature: Date:This section of Part VII to be completed by STUDENT-ATHLETES ONLYPERMISSION FOR MEDICAL RECORDS RELEASEI hereby authorize Susquehanna University’s Sport Medicine Staff and its insurance agent, to inspect or secure copies of the Susquehanna University Health Center’s health record. I also consent for the release of medical records of past and future confinements and/or disabilities that may affect my ability to participate in intercollegiate athletic competition. A photo copy of this authorization shall be deemed as effective and valid as the original.Student-Athlete’s Signature: Date:ACKNOWLEDGEMENT OF RISK AND INFORMED CONSENTI realize that participation in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I understand there are risks including and not limited to death or paralysis, brain damage, cardiac arrest, serious injury to internal organs and to bones, joints, ligaments, muscles, tendons and other serious injury or impairment to other aspects of my general health and well-being. I understand that the dangers and risks of participating in sports also include the potentially high cost of medical care and impairment of my future ability to earn a living, to engage in other business, social and recreational activities and generally to enjoy life. Recognizing these risks, I choose to participate in the sport(s) of my choice at Susquehanna University.Student-Athlete’s Signature: Date:Part VIII – CONCUSSION STATEMENTThis section to be completed by STUDENT-ATHLETES ONLY.Susquehanna University Student-Athlete Concussion StatementI understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. I have read and understand the NCAA Concussion Fact Sheet. This sheet is located at . After reading the NCAA Concussion fact sheet, I am aware of the following information: A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer. A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage and even death.Student-Athlete’s Signature: Date:Part IX – SICKLE CELL TRAIT TESTINGThis section to be completed by STUDENT-ATHLETES ONLY.I understand and acknowledge that the NCAA and Susquehanna University require all student-athletes to have knowledge of their sickle cell trait status. Susquehanna University recommends that all student-athletes who are unable to confirm their sickle cell trait status undergo testing prior to participation in any intercollegiate activity.Sickle cell trait is an inherited condition of the oxygen carrying protein, hemoglobin, in the red blood cells.Sickle cell trait is a common condition affecting more than 3 million Americans.Although sickle cell trait is most predominant in African Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean and South/Central American ancestry, persons of all races may test positive for sickle cell trait.Sickle cell trait has been associated with a condition known as exertional rhabdomyolysis, renal failure, and death. Complicating factors include extreme exertion, increased heat, altitude, and dehydration.Sickle cell trait is usually benign but during intense sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells which can accumulate in the bloodstream and “logjam” blood vessels, leading to a collapse from the rapid breakdown of muscle starved of blood.After reviewing the above information I have elected to (please check appropriate box):□ I know my sickle cell trait status and can provide documentation of the results.□ I will get tested and provide documented proof of my sickle cell trait status to the sports medicine staff.□ I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless Susquehanna University from any and all costs, liabilities, expenses, claim demands, or causes of actions on account of any loss or personal injury that might result from my non-compliance with the NCAA and Susquehanna University recommendation of knowing my sickle cell trait status.Student-Athlete’s Signature: Date: ................
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