Pre-season athlete survey

Attachment D

Pre-Season Athlete 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: Athlete

Thank you for agreeing to be in our study. Please put your answers in the space provided or circle your answer. If you don’t know the answer to a question, you can ask your parent for assistance. This survey contained 19 questions and should take less than 10 minutes of your time to complete.

The first few questions are about you and your experience playing soccer.

1. Gender:

   1. Male

   2. Female

2. Age: __ __ years

3. Ethnicity (Choose one):

   1. Hispanic or Latino

   2. Not Hispanic or Latino

   3. Unknown

4. Race Category (Choose all that apply):

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African-American

   4. Native Hawaiian or Other Pacific Islander

   5. White

   6. Unknown

5. Do you qualify for school lunch?

   1. Yes

   2. No

6. How long have you played soccer on a team? __ __ years

7. Which soccer teams did you or are you playing for this year? (Check all that apply)

   1. High school

   2. Club recreational

   3. Club premier

   4. Club select

8. How often do you head the ball?

   1. Never

   2. Rarely

   3. Sometimes

   4. Frequently (a few times per game)

   5. Very often (many times per game)

9. While playing any sport, have you 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 were you unconscious (passed out)? ______minutes

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

SKIP TO QUESTION 16

10. While playing any sport, how many times have you had a hit to your head or body AND had any of the above symptoms? ___ ___

11. Have you 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How many times? ____ _____

12. Have you ever had a hit to your 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? ____ ____

13. Have 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? ____ _____

14. Using the list below, score yourself on the following symptoms based on how you are feeling RIGHT NOW.

	None	Mild		Moderate		Severe
Headache	0	1	2	3	4	5	6
“Pressure in head”	0	1	2	3	4	5	6
Nausea or vomiting	0	1	2	3	4	5	6
Dizziness	0	1	2	3	4	5	6
Blurred vision	0	1	2	3	4	5	6
Balance problems	0	1	2	3	4	5	6
Sensitivity to light	0	1	2	3	4	5	6
Sensitivity to noise	0	1	2	3	4	5	6
Feeling slowed down	0	1	2	3	4	5	6
Feeling like “in a fog”	0	1	2	3	4	5	6
“Don’t feel right”	0	1	2	3	4	5	6
Difficulty concentrating	0	1	2	3	4	5	6
Difficulty remembering	0	1	2	3	4	5	6
Fatigue or low energy	0	1	2	3	4	5	6
Confusion	0	1	2	3	4	5	6
Drowsiness	0	1	2	3	4	5	6
Trouble falling asleep	0	1	2	3	4	5	6
More emotional	0	1	2	3	4	5	6
Irritability	0	1	2	3	4	5	6
Sadness	0	1	2	3	4	5	6
Nervous or anxious	0	1	2	3	4	5	6

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.

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

    1. Yes

    2. N

       If No, SKIP TO QUESTION 24

       
       o

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

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

    1. Coach

    2. Teacher

    3. Principal, athletic director or other school official

    4. Other______________________________

18. 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 _________

19. 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

20. 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

21. 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______________

22. Did you have to sign any forms about concussion in the past year in order to play your 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.

Screenshot

0