ImPACT™ Test Informed Consent

ImPACT™ Test Informed Consent

Dear Parent/Guardian:
We are currently utilizing an innovative program for evaluating and treating head injuries (e.g., concussion). In order to better manage concussions sustained by our student-athletes, we have partnered with Northeastern Rehabilitation Associates to acquire a software tool called ImPACT™ (Immediate Post Concussion Assessment and Cognitive Testing). ImPACT™ is a computerized exam and used in many sports programs across the country that can be used by a trained healthcare professional to evaluate the severity of the head injury and the athlete’s recovery from that injury. Ideally, the computerized exam is given to athletes before beginning contact sport practice or competition. There are currently 2 versions used to assess baseline measures:

  1. The ImPACT™ Baseline Test is administered to athletes ages 12 and up. Total test time is approximately 45 minutes. The test itself, is a non-invasive test set up in a video-game type format and takes about 20-30 minutes to complete. This test can be performed within a clinical setting or at a computer compatible to the ImPact software. If you decide to utilize the home version, the test system will verify your computer’s compatibility as well as provide instructions on how testing is completed.
  2. The Pediatric ImPACT™ administered to athletes ages 11 and under. Total test time is approximately 30 minutes. The test itself, is a non-invasive test set up in a video-game type format and takes about 20-minutes to complete. This test is performed on an iPad and must be administered by a trained professional one-on-one.

About the test: The ImPACT™ test tracks information such as memory, reaction time, speed, and concentration. In addition, to help healthcare providers better understand the athlete’s particular healthcare situation, there also are questions about the athlete’s health history as well as current symptoms that he or she may be experiencing. ImPACT is not an IQ test. If a concussion is suspected, the athlete may be required to re-take the test. The athlete’s performance on the post-injury test will be compared to his/her performance on the baseline and any differences in performance will be evaluated by a healthcare provider. The test data will enable healthcare professionals to determine when return-to-activity is appropriate and safe for the injured child. The ImPACT testing procedures are non-invasive and pose no known risks to your student-athlete.

Please complete return the attached page with the appropriate signatures prior to your student-athlete’s testing date. Please direct any questions or concerns to Northeastern Rehabilitation Associates, or your organizations administrators

I have read and understood the above information and give permission for my son/daughter to take the ImPACT™ Baseline Concussion Test.

MM slash DD slash YYYY
MM slash DD slash YYYY