Pre-season parent survey

Attachment E

Pre-Season Parent Survey

Form Approved
OMB No: 0920-XXXX
Exp. Date:

Public Reporting burden of this collection of information is estimated at 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Date __ __ / __ __ / __ __

Pre-Season Survey: Parent

Thank you for agreeing to be in our study. Please put your answers in the space provided or circle your answer. This survey contains 19 questions and should take less than 10 minutes of your time to complete.

1. What is your relationship to the child you are filling this survey about?

   1. Mother

   2. Father

   3. Step-mother

   4. Step-father

   5. Grandmother

   6. Grandfather

   7. Foster parent

   8. Other _________________

The first few questions are about YOUR CHILD and his/her experience playing soccer.

2. Gender:

   1. Male

   2. Female

3. Age: __ __ years

4. How long has YOUR CHILD played soccer on a team? __ __ years __ __ months

5. Which soccer teams did YOUR CHILD play for this year? (Check all that apply)

   1. High school

   2. Club recreational

   3. Club premier

   4. Club select

6. How often does YOUR CHILD head the ball?

   1. Never

   2. Rarely

   3. Sometimes

   4. Frequently (a few times per game)

   5. Very often (many times per game)

7. While playing any sport, has YOUR CHILD ever had a hit to your head or body AND then had any of the following symptoms?

Circle all that apply:

1. Headache

2. “Pressure in head”

3. Nausea or vomiting

4. Dizziness

5. Blurred vision

6. Balance problems

7. Sensitivity to light

8. Sensitivity to noise

9. Feeling slowed down

10. Feeling like “in a fog”

11. “Don’t feel right”

12. Difficulty concentrating

13. Difficulty remembering

14. Fatigue or low energy

15. Confusion

16. Drowsiness

17. Trouble falling asleep

18. More emotional

19. Irritability

20. Sadness

21. Nervous or anxious

22. Loss of consciousness (passed out)

    1. How many minutes was your child unconscious (passed out)? ______minutes

23. Never have had these things happen while playing any sport

SKIP TO QUESTION 13

8. While playing any sport, how many times has YOUR CHILD had a hit to your head or body AND had any of the above symptoms? ___ ___

9. Has YOUR CHILD ever been diagnosed with a concussion, mild traumatic brain injury, minor head injury, or head injury from playing soccer or another sport?

   1. No

   2. Yes

10. How many times has YOUR CHILD been diagnosed with a concussion from playing soccer or another sport? ___ ___

11. Has YOUR CHILD ever had a hit to his/her head or body in an accident not involving sports (like a car accident or a bike crash) AND had any of the previously described symptoms (see page 2)?

    1. No

    2. Yes How many times? ____ _____

12. Has YOUR CHILD you ever been diagnosed with a concussion, mild traumatic brain injury, minor head injury, or head injury from an accident not involving sports?

    1. No

    2. Yes How many times? ____ ___

In this next section we want to ask you some questions about any information YOU may have been given or seen about concussions or head injuries in sports.

13. Has anyone given you any information about concussion or head injury in the past year?

    1. Yes

    2. N

       If No, SKIP TO QUESTION 20

       
       o

14. How many times has someone given you information about concussion in the past year? ______ _______

15. Who gave you this information? (Circle all that apply)

    1. Child’s coach

    2. Child’s teacher

    3. Principal, athletic director or other school official

    4. Other______________________________

16. What kind of information did you receive about concussion in the past year? (Check all that apply):

    1. Video

    2. Pamphlet or information sheet

    3. A talk using computer slides

    4. A talk

    5. A link to information on the web

    6. Other _________

17. Have you received information called “Heads Up,” with any of these logos?

1. Yes How many times has someone given you “Heads Up” information in the past year? ____ _____

2. No

3. Unsure

18. Have you ever seen any posters about concussion?

    1. Yes Did these posters have the Heads Up logo? (See above)

       1. Yes

       2. No

       3. Unsure

    2. No

    3. Unsure

19. Have you learned about sports concussion on your own from any of the

following sources (check all that apply)?

1. Online video

2. Online news

3. Online blog

4. Online medical website (Web MD, Medline plus, Mayo clinic)

5. ESPN/Sports center

6. TV or radio

7. Went to a talk

8. Discussion with physician

9. Printed material (newspaper, magazine, etc)

10. “Heads Up” from the Centers for Disease Control and Prevention (CDC)

11. State athletic association website

12. Other______________

20. Did you have to sign any forms about concussion in the past year in order for your child to play their sport?

    1. Yes

    2. No

    3. Unsure

This section covers general concussion knowledge.

1. There is a possible risk of death if a second concussion occurs before the first one has healed.

   1. True

   2. False

   3. Unsure

2. People who have had one concussion are more likely to have another concussion.

   1. True

   2. False

   3. Unsure

3. In order to be diagnosed with a concussion, you have to be knocked out.

   1. True

   2. False

   3. Unsure

4. A concussion can only occur if there is a direct hit to the head.

   1. True

   2. False

   3. Unsure

5. Being knocked unconscious always causes permanent damage to the brain.

   1. True

   2. False

   3. Unsure

6. Symptoms of a concussion can last for several weeks.

   1. True

   2. False

   3. Unsure

7. Sometimes a second concussion can help a person remember things that were forgotten after the first concussion.

   1. True

   2. False

   3. Unsure

8. After a concussion occurs, brain imaging (e.g., CAT Scan, MRI, X-Ray, etc.) typically shows visible physical damage (e.g., bruise, blood clot) to the brain.

   1. True

   2. False

   3. Unsure

9. If you receive one concussion and you have never had a concussion before, you will become less intelligent.

   1. True

   2. False

   3. Unsure

10. After 10 days, symptoms of a concussion are usually completely gone.

    1. True

    2. False

    3. Unsure

11. After a concussion, people can forget who they are and not recognize others but be perfect in every other way.

    1. True

    2. False

    3. Unsure

12. Concussions can cause emotional symptoms (such as sadness or crying).

    1. True

    2. False

    3. Unsure

13. An athlete who gets knocked out after getting a concussion is experiencing a coma.

    1. True

    2. False

    3. Unsure

14. There is rarely a risk to long-term health and well-being from multiple concussions.

    1. True

    2. False

    3. Unsure

This last section covers attitudes about concussion.

15. I would continue playing a sport while also having a headache that resulted from a minor concussion.

    1. Strongly agree

    2. Agree

    3. Neither agree nor disagree

    4. Disagree

    5. Strongly disagree

16. I feel that coaches need to be extremely cautious when determining whether an athlete should return to play.

    1. Strongly agree

    2. Agree

    3. Neither agree nor disagree

    4. Disagree

    5. Strongly disagree

17. I feel that concussions are less important than other injuries.

    1. Strongly agree

    2. Agree

    3. Neither agree nor disagree

    4. Disagree

    5. Strongly disagree

18. I feel that an athlete has a responsibility to return to a game even if it means playing while still experiencing symptoms of a concussion.

    1. Strongly agree

    2. Agree

    3. Neither agree nor disagree

    4. Disagree

    5. Strongly disagree

19. I feel that an athlete who is knocked unconscious should be taken to the emergency room.

    1. Strongly agree

    2. Agree

    3. Neither agree nor disagree

    4. Disagree

    5. Strongly disagree

You are finished! Thank you for filling out this survey.

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