Individualized Concussion Program For High Schools

1. Name:____________________________ Zone:_________ Week of:____________
Academic Accommodations
Homework:
-No repetition (multiples of same type of question/equation) -Reduced reading
-Limit computer assignments -Allow extra time for assignments to be completed
-Limited to ____min/day(per subject) -NO Homework
-Extra time/delayed turn in date -No computer assignments
Testing:
-Allow extra time -Allow testing across multiple sessions -Reduce length
-Break up test into multiple parts -Multiple choice instead of extended response
-Word bank for fill in the blank -True/False questions
-Test in quiet environment -Test makeup: must be different subjects in one day
-Only ___ Tests/Quizzes per day -NO Testing/Quizzes -Quizzes only
Other Accommodations:
-Avoid busy environments -Put head down during note taking (auditory learning)
-Allow to leave class if symptoms worsen (go to Main Office) -NO movies
-Limit class participation -Seating: move front to back of room -Peer notetaking
-Transfer class early -Lunch in quiet room -NO reading in class -Clear desk
-NO computer use -NO smartboard/PowerPoints -NO weightlifting/PE
-Periodic head down is ok - No Band/Choir (No Loud Music)
-NoPepRally/Assembly/Mass -No Field Trip
ImPACT TESTING RESULTS: Student is testing low on the following areas:
o Verbal Memory. (Remembering words spoken and read.)
o Visual Memory. (Remembering symbols and numbers.)
o Visual Motor Speed. (Processing speed)
o Reaction Time.

2. Concussion Zone Guidelines
Zone Activity Level Strategies toward Recovery Definition and Classroom Interventions.
1
Red
No School
Symptomatic at
rest
No physical
activity
Not attending school
ImPACT Testing
Student suffered concussion and is resting
both cognitively and at home. Avoid all
academic work. Reduce the pace or
quantity of work for several days.
2
Orange
Limited School
Day
Limited Physical
class attendance
No Physical
Activity
Class attendance limited
Clear desk, no written desk
work (auditory only)
Limited classwork
Peer note taking
Periodic break from active
classroom participation (head
down on desk)
Refer to academic
accommodations sheet for
each student
ImPACT Testing
Continued monitoring by athletic trainer
Benefit from:
 Rest breaks during class
 Head down in class or seated with
eyes closed not actively working but
actively listening
 Rest in front office up to 20 minutes
 Limited classwork/testing – 1 quiz
per week
 Less reading, more listening
 Utilize teacher or peer notes
 Develop and maintain schedule for
assignments
Please be observant of changes in student
physical or cognitive activity and report
concerns to front office
Be supportive – stress will prolong student’s
healing time
3
Yellow
Full day of school
Limited class time
with possible
partial mental
class attendance
Return To Play
Progression:
Limited physical
activity. Low
impact.
Clear desk
Classroom participation as
tolerated
Limited classwork
May need period of mental
and/or physical rest within
classroom (head down on
desk)
Refer to academic
accommodations sheet for
each student
ImPACT Testing used to move
to Blue
Student attempting to complete full school
day but may need limit time attending
classes that cause concussion symptoms to
return or intensify.
Benefit from:
 Rest breaks during class
 Head down on desk or seated with
eyes closed not actively working,
but actively listening
 Rest in front office for up to 20
minutes
 Increased amounts of
classwork/testing
 1 test
 Emphasis on formative rather than
summative assessments
 Develop and maintain schedule for
completing assignments
Please be observant of changes in student
physical or cognitive activity and report
concerns to front office

3. 4
Blue
Full class
attendance
(physical and
mental) with
instructional
strategies
Return To Play
Progression:
Partial Practice,
moderate-high
impact. No
Competition.
Attending full classes
Instructional strategies in
use based on student needs
Final ImPACT Test to move
to Green Zone
Set a deadline for all missing
assignments and tests to
move on to Green.
Should be attending full day of school and
participating in entire class period with
minimal strategies in place.
Benefit from:
Increased amounts of classwork/testing,
including summative assessments
2 tests
Actively working on completing missed
assignments
Please alert front office if student is not
able to maintain classroom attendance
due to concussion symptoms
5
Green
Full class without
instructional
strategies
Fully back to
physical activity
and competition.
No instructional strategies
needed
Student should be fully participating in
class and returning to athletic participation
Student should be actively working or
completed make up work as appropriate.
Be supportive
Please be observant of changes in student
physical or cognitive activity and report
concerns to front office
Post Follow up 1 week
post return to
unrestricted
activity
Verify student in preforming
at pre-concussion level in
classroom
Notify front office if student has not
returned to pre-concussion academic
ability in your class.