NCCSIR Catastrophic Injury Application

Report a Catastrophic Incident

Please complete the following information. All information will be kept confidential. Due to federal privacy laws, information from medical records or student records should not be reported on this site. If you prefer to report the event over the phone, please call the NCCSIR at 919-843-8357. For technology help, please call Datalys at 855-832-4222.

Please correct these issues in your input below:

Reporter Information

Reporter Name

Reporter Email Address

Reporter Phone Number

Can we contact you if follow up is needed?

Reporter Role

Describe:

Injured Athlete Is 18 Years Old or Older

Injured Athlete Is Able to Speak For Themselves

Parent/Guardian Email Address

Parent/Guardian Phone Number

Athlete Email Address

Athlete Phone Number

Athlete Information

Athlete's First Name

Athlete's Middle Name

Athlete's Last Name

Athlete's Age

Athlete's Sex

Athlete's Race (check all that apply)

Athlete's Ethnicity

Athlete's City

Athlete's State

Describe:

Athlete's Primary Sport

Describe:

Injury Information

Injury/Illness Date

City Where Injury/Illness Occurred

State Where Injury/Illness Occurred

Describe:

Please briefly describe the injury event and how it happened (1000 characters or less)

Sport (at the time of the injury event)

Describe:

Sport Level

Describe:

Collegiate Affiliation

Describe:

Collegiate Sport Level

Describe:

High School Sport Level

Describe:

Middle School Sport Level

Describe:

Recreational Affiliation

Sponsored Recreational Level

Athlete participates in a school, semi-professional, or professional sponsored sport

Describe:

Event Activity

Describe:

Location

Describe:

Location Venue

Type of Event

Describe:

Sport Position

Describe:

Select a Sport for full listing of options. Loading...

Player Action

Describe:

Select a Sport for full listing of options. Loading...

Mechanism of Injury or Illness

Describe:

Detailed Mechanism of Injury or Illness

Describe:

Select a Sport and a Mechanism for full listing of options. Loading...

Injury/Illness Category

Describe:

To the best of your knowledge, what was the specific cause of sudden cardiac arrest or death

Fatality

If known, please provide date of death

Dispositions (check all that apply)

Athlete taken to a hospital

Athlete transported in an ambulance / EMS vehicle

Consent Information

We appreciate the information that you shared with us about this event.

We would like to ask you some additional questions about the event (such as the circumstances surrounding the event and medical care provided). If you would like to participate, we ask that you please review and complete the consent forms below. If you are not sure or not interested, you may select "Not now" or "No" for each option, and submit the report by clicking the "Submit Report" button below.

At this time, we would like you to:

Read the Athlete Consent Form and check the appropriate box based on your interest
Read the HIPAA Authorization Form and check the appropriate box based on your interest

You may also request that we call you to go over these forms with you or for paper copies of the forms to be mailed to you. We appreciate any information you are willing to share with us and thank you for your help. Please feel free to contact us (919-843-8357 or nccsir@unc.edu) if you have any questions or need additional information.

Consent Information

We appreciate the information that you shared with us about this event.

We would like to ask you some additional questions about the event (such as the circumstances surrounding the event and medical care provided). If you would like to participate, we ask that you please review complete the consent forms below. If you are not sure or not interested, you may select "Not now" or "No" for each option, and submit the report by clicking the "Submit Report" button below.

At this time, we would like you to:

Read the Next-of-Kin Consent Form and check agree box to participate
Read the HIPAA Authorization Form and check agree box to participate

You may also request that we can you to go over these forms with you or for paper copies of the forms to be mailed to you. We appreciate any information you are willing to share with us and thank you for your help. Please feel free to contact us (919-843-8357 or nccsir@unc.edu) if you have any questions or need additional information.

Consent Information

We appreciate the information that you shared with us about this event.

We would like to ask you some additional questions about the event (such as the circumstances surrounding the event and medical care provided). If you would like to participate, we ask that you please review complete the consent forms below. If you are not sure or not interested, you may select "Not now" or "No" for each option, and submit the report by clicking the "Submit Report" button below.

At this time, we would like you to:

Read the Parental Consent Form and check agree box to participate
Read the HIPAA Authorization Form and check agree box to participate
Have the injured minor athlete complete the Child Assent Form

We appreciate the information that you shared with us about this event.

We would like to ask you some additional questions about the event (such as the circumstances surrounding the event and medical care provided). If you would like to participate, we ask that you please review complete the consent forms below. If you are not sure or not interested, you may select "Not now" or "No" for each option, and submit the report by clicking the "Submit Report" button below.

At this time, we would like you to:

Read the Parental Consent Form and check agree box to participate
Read the HIPAA Authorization Form and check agree box to participate

Consent to Participate in a Research Study - Adult Participants (Over 18 Years of Age)

IRB Study #: 05-0018

Form: B3-ATH

Consent Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

Principal Investigator: Kristen Kucera, MSPH, PhD, ATC
UNC-Chapel Hill Department: Exercise and Sport Science
Mailing Address: 209 Fetzer Hall, CB#8700, Chapel Hill, NC 27599
UNC-Chapel Hill Phone Number: 919-843-8357
Email Address: kkucera@email.unc.edu
Co-Investigators: Robert C. Cantu, MD; Douglas J. Casa, PhD, ATC; Jonathan Drezner, MD; Johna Register-Mihalik, PhD, ATC

What are some general things you should know about research studies?

You are being asked to participate in a research. Research studies are designed to obtain new knowledge and this new information may help people in the future. They may or may not benefit you, and there may also be risks.

It is important for you to know that your participation in this study is voluntary. You may refuse to join, or you may withdraw your consent for any reason and at any time.

A copy of this consent form is enclosed for you to keep for your records. You should ask the researchers named above, or staff members who may assist them, any questions you have about this study at any time.

What is the purpose of this study?

The purpose of this research study is to learn about catastrophic deaths, disability, and/or serious sports-related injuries and illnesses among middle school, high school and collegiate athletes, and semi-professional and professional athletes in order to help make sports safer for the participants. You are being asked to participate in this study because we have received information indicating that you sustained a catastrophic injury during a sporting activity.

How many people will take part in this study?

Approximately 150 athletes sustain a catastrophic sports injury each year. We are inviting athletes, family members, school and team officials, and medical providers to provide information about the nature of the injuries and the circumstances surrounding the injury event.

What will happen if you take part in this study?

If you agree to participate, we will:

1) Ask you to participate in a 30-45 minute telephone interview consisting of questions about your age, height, weight, playing experience, previous injury experience, the circumstances of the injury event, the type of injuries, and subsequent medical treatment provided. Your participation in the study is voluntary so if there is a question or questions that you do not want to answer, that is not a problem—just tell the interviewer to go on to the next question.

2) We will also ask your school staff members (athletic trainer, athletic director, coach, and/or other school staff) to participate in a similar interview.

3) For certain injuries we may also ask to interview your personal physician and the medical personnel who treated your injuries. We may request radiological images (x-rays, MRIs, CT scans) and/or request other medical information such as medical records about your injury or information regarding treatment provided.

4) We may also request other personal items of scientific relevance to the injury, for example video recordings of the injury, football helmets for head/neck injuries or clothing for exertional heat stroke. These items will be evaluated and archived.

5) We may also contact you again if more information is needed.

6) This is an ongoing study that has been active at UNC-CH since 1982-1983. We anticipate that the project will continue indefinitely. All files will be kept and stored securely. Consent can be withdrawn for any reason and at any time, but must be done so in writing to the principal investigator on the top of this form.

What are the possible risks or discomforts involved from being in this study?

Although extremely rare, there are some potential risks involved with this study. There is the possibility that you may experience emotional distress when asked questions about the injury. Any problems or concerns should be reported to the researchers, who have been trained to provide assistance to aid in management of emotional distress.

What are the possible benefits involved in being in this project?

There are no direct benefits expected for you from being in this study. However, we hope your contribution will help us learn more about preventing injuries and making sports safer for future athletes.

How will your privacy be protected?

All information that you tell us will be kept confidential, as will any information obtained from related interviews with school officials or medical personnel, and medical records. For instance, no information from one interview participant will be shared with another. Names of individuals, schools or teams will never be identified in any report or publication about this study. Interview forms and other paper records will be in stored in locked offices and access will be limited to the research team. Electronic data are stored on secure computers. Access is limited to study staff using individual passwords. Although every effort will be made to keep research records private, there may be times when federal or state law requires the disclosure of such records, including personal information. This is very unlikely, but if disclosure is ever required, UNC-Chapel Hill will take steps allowable by law to protect the privacy of personal information.

Will you receive anything for being in this study?

You will not receive any compensation for taking part in this study.

Will it cost you anything for you to be in this study?

There will be no costs to you for participating in this study.

What if you have questions about this study?

You have the right to ask, and have answered, any questions you may have about this research. If you have questions or concerns, you should contact the researchers listed on the first page of this form.

What if you have questions about your rights as a research participant?

All research on human volunteers is reviewed by a committee that works to protect your rights and welfare. If you have questions or concerns about your rights as a research subject, you may contact (anonymously if you wish) the Institutional Review Board at 919-966-3113 or by email to IRB_subjects@unc.edu.

Funding Sources: This research is funded by the National Collegiate Athletic Association (NCAA), National Federation of State High School Associations (NFHS), American Football Coaches Association (AFCA), National Athletic Trainers' Association (NATA), National Operating Committee on Standards for Athletic Equipment (NOCSAE), and American Medical Society for Sports Medicine (AMSSM). This means that the research team is being paid by the sponsors for doing the study. In addition, a family member of Johna Register-Mihalik, a co-investigator on this study, has received money from NOCSAE for work that is not part of this study. These activities may include consulting, service on advisory boards, giving speeches, or writing reports.

I have read the information provided above. I have asked all the questions I have at this time. I voluntarily agree to participate in this research project.

Next-of-Kin Consent for Adult to Participate in a Research Study

IRB Study #: 05-0018

Form: B4-NOK

Consent Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

What are some general things you should know about research studies?

You are being asked to provide consent for the athlete to take part in a research study. Research studies are designed to obtain new knowledge and this new information may help people in the future. They may or may not benefit the athlete, and there may also be risks.

It is important for you to know that their participation in this study is voluntary. You may refuse to give consent, or you may withdraw your consent for any reason and at any time.

What is the purpose of this study?

The purpose of this research study is to learn about catastrophic deaths, disability, and/or serious sports-related injuries and illnesses among middle school, high school and collegiate athletes, and semi-professional and professional athletes in order to help make sports safer for the participants. You and the athlete are being asked to participate in this study because we have received information indicating that he/she sustained a catastrophic injury during a sporting activity.

How many people will take part in this study?

What will happen if you or the athlete takes part in this study?

If you provide consent for the athlete to participate, we will:

1) Ask you to participate in a 30-45 minute telephone interview consisting of questions about the athlete’s age, height, weight, playing experience, previous injury experience, the circumstances of the injury event, the type of injuries, and subsequent medical treatment provided. Participation is voluntary so if there is a question or questions that you do not want to answer, that is not a problem—just tell the interviewer to go on to the next question.

2) We will also ask the athlete’s school staff members (athletic trainer, athletic director, coach, and/or other school staff) to participate in a similar interview.

3) For certain injuries we may also ask to interview the athlete’s personal physician and the medical personnel who treated their injuries. We may request radiological images (x-rays, MRIs, CT scans) and/or other medical information such as medical records about the athlete’s injury or information regarding treatment provided.

5) We may also contact you again if more information is needed.

What are the possible risks or discomforts involved from being in this study?

Although extremely rare, there are some potential risks involved with this study. There is the possibility that you and/or the athlete may experience emotional distress when asked questions about the injury. Any problems or concerns should be reported to the researchers, who have been trained to provide assistance to aid in management of emotional distress.

What are the possible benefits involved in being in this project?

There are no direct benefits expected for you or the athlete from being in this study. However, we hope your contribution will help us learn more about preventing injuries and making sports safer for future athletes.

How will your privacy and that of the athlete be protected?

Will anything be received for being in this study?

You or the athlete will not receive any compensation for taking part in this study.

Will it cost anything to be in this study?

There will be no costs for participating in this study.

What if you have questions about this study?

You and the athlete have the right to ask, and have answered, any questions you may have about this research. If you have questions or concerns, you should contact the researchers listed on the first page of this form.

What if you have questions about your rights as a research participant?

All research on human volunteers is reviewed by a committee that works to protect the athlete’s rights and welfare. If you or the athlete has questions or concerns about their rights as a research subject, you may contact (anonymously if you wish) the Institutional Review Board at 919-966-3113 or by email to IRB_subjects@unc.edu.

I have read the information provided above. I have asked all the questions I have at this time. I give consent for the athlete to participate in this research project.

Parental/Guardian Permission for a Child to Participate in Research

IRB Study #: 05-0018

Form: B1-PAR

Consent Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

What are some general things you should know about research studies?

You are being asked to participate in a research study and allow your child to take part in the same study. Research studies are designed to obtain new knowledge and this new information may help people in the future. They may or may not benefit your child, and there may also be risks.

It is important for you to know that your family’s participation in this study is voluntary. You may refuse to give consent, or you may withdraw your consent for any reason and at any time.

A copy of this consent form is enclosed for you to keep for your records. You and your child should ask the researchers named above, or staff members who may assist them, any questions you have about this study at any time.

What is the purpose of this study?

The purpose of this research study is to learn about catastrophic deaths, disability, and/or serious sports-related injuries and illnesses among middle school, high school and collegiate athletes, and semi-professional and professional athletes in order to help make sports safer for the participants. You and your child are being asked to participate in this study because we have received information indicating that your child sustained a catastrophic injury during a sporting activity.

How many people will take part in this study?

Approximately 150 athletes sustain a catastrophic sports injury each year. We are inviting athletes, family members, school and, team officials and medical providers to provide information about the nature of the injuries and the circumstances surrounding the injury event.

What will happen if your family takes part in this study?

If you and your child agree to participate, we will:

1) Ask you and/or your child to participate in a 30-45 minute telephone interview consisting of questions about your child’s age, height, weight, playing experience, previous injury experience, the circumstances of the injury event, the type of injuries, and subsequent medical treatment provided. Participation by you and your child is voluntary so if there is a question or questions that you do not want to answer, that is not a problem—just tell the interviewer to go on to the next question. Similarly, your child may skip any question.

2) We will also ask your child’s school staff members (athletic trainers, athletic directors, coaches, and/or other school staff) to participate in a similar interview.

3) For certain injuries we may also ask to interview your child’s personal physician and the medical personnel who treated their injuries. We may request radiological images (x-rays, MRIs, CT scans) and/or other medical information such as medical records about your child’s injury or information regarding treatment provided.

5) We may also contact you again if more information is needed. We will not contact your child without contacting you first.

What are the possible risks or discomforts involved from being in this study?

Although extremely rare, there are some potential risks involved with this study. There is the possibility that you and/or your child may experience emotional distress when asked questions about the injury. Any problems or concerns should be reported to the researchers, who have been trained to provide assistance to aid in management of emotional distress.

What are the possible benefits involved in being in this project?

There are no direct benefits expected for you or your child from being in this study. However, we hope your contribution will help us learn more about preventing injuries and making sports safer for future athletes.

How will your privacy and that of your child’s be protected?

All information that you and your child tell us will be kept confidential, as will any information obtained from related interviews with school officials or medical personnel, and medical records. For instance, no information from one interview participant will be shared with another. Names of individuals, schools or teams will never be identified in any report or publication about this study. Interview forms and other paper records will be in stored in locked offices and access will be limited to the research team. Electronic data are stored on secure computers. Access is limited to study staff using individual passwords. Although every effort will be made to keep research records private, there may be times when federal or state law requires the disclosure of such records, including personal information. This is very unlikely, but if disclosure is ever required, UNC-Chapel Hill will take steps allowable by law to protect the privacy of personal information.

Will you or your child receive anything for being in this study?

You or your child will not receive any compensation for taking part in this study.

Will it cost you anything for you or your child to be in this study?

There will be no costs to you or your child for participating in this study.

What if you or your child has questions about this study?

You and your child have the right to ask, and have answered, any questions you may have about this research. If you have questions or concerns, you should contact the researchers listed on the first page of this form.

What if you or your child has questions about your child’s rights as a research participant?

All research on human volunteers is reviewed by a committee that works to protect your child’s rights and welfare. If you or your child has questions or concerns about your child’s rights as a research subject, you may contact (anonymously if you wish) the Institutional Review Board at 919-966-3113 or by email to IRB_subjects@unc.edu.

Parental/Guardian Permission for a Child to Participate in Research

IRB Study #: 05-0018

Form: B2-PAR

Consent Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

What are some general things you should know about research studies?

It is important for you to know that your family’s participation in this study is voluntary. You may refuse to give consent, or you may withdraw your consent for any reason and at any time.

What is the purpose of this study?

The purpose of this research study is to learn about catastrophic deaths, disability, and/or serious sports-related injuries and illnesses among middle school, high school and collegiate athletes, and semi-professional and professional athletes in order to help make sports safer for the participants. You and your child are being asked to participate in this study because we have received information indicating that your child sustained a catastrophic injury during a sporting activity.

How many people will take part in this study?

What will happen if your family takes part in this study?

If you agree to participate, we will:

1) Ask you to participate in a 30-45 minute telephone interview consisting of questions about your child’s age, height, weight, playing experience, previous injury experience, the circumstances of the injury event, the type of injuries, and subsequent medical treatment provided. Participation is voluntary so if there is a question or questions that you do not want to answer, that is not a problem—just tell the interviewer to go on to the next question.

2) We will also ask your child’s school staff members (athletic trainer, athletic director, coach, and/or other school staff) to participate in a similar interview.

4) We may also request other personal items of scientific relevance to the injury, for example football helmets for head/neck injuries or clothing for exertional heat stroke. These items will be evaluated and archived.

5) We may also contact you again if more information is needed.

What are the possible risks or discomforts involved from being in this study?

What are the possible benefits involved in being in this project?

How will your privacy and that of your child’s be protected?

All information that you tell us will be kept confidential, as well as any information obtained from related interviews with school officials or medical personnel, and medical records. For instance, no information from one interview participant will be shared with another. Names of individuals, schools or teams will never be identified in any report or publication about this study. Interview forms and other paper records will be in stored in locked offices and access will be limited to the research team. Electronic data are stored on secure computers. Access is limited to study staff using individual passwords. Although every effort will be made to keep research records private, there may be times when federal or state law requires the disclosure of such records, including personal information. This is very unlikely, but if disclosure is ever required, UNC-Chapel Hill will take steps allowable by law to protect the privacy of personal information.

Will you receive anything for being in this study?

You will not receive any compensation for taking part in this study.

Will it cost anything for you to be in this study?

There will be no costs to you for participating in this study.

What if you have questions about this study?

What if you have questions about your rights as a research participant?

All research on human volunteers is reviewed by a committee that works to protect your rights and welfare. If you has questions or concerns about your rights as a research subject, you may contact (anonymously if you wish) the Institutional Review Board at 919-966-3113 or by email to IRB_subjects@unc.edu.

I have read the information provided above. I have asked all the questions I have at this time. I voluntarily give permission to allow my child to participate in this research project.

HIPAA Authorization for Use and Disclosure of Health Information for Research Purposes

Adult Authorization

IRB Project #: 05-0018

Form: C3

Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

Principal Investigator: Kristen Kucera, MSPH, PhD, ATC
UNC-Chapel Hill Department: Exercise and Sport Science
Mailing Address: 209 Fetzer Hall, CB#8700, Chapel Hill, NC 27599
Telephone: 919-843-8357
Email: kkucera@email.unc.edu
Co-Investigators: Robert C. Cantu, MD; Douglas J. Casa, PhD, ATC; Jonathan Drezner, MD; Johna Register-Mihalik, PhD, ATC

This is a permission called a "HIPAA authorization." It is required by the "Health Insurance Portability and Accountability Act of 1996" (known as "HIPAA") in order for us to obtain information from your medical records.

1. If you sign this HIPAA authorization form, you are giving your permission for the following persons or groups to give the researchers relevant information about your catastrophic sports injury.

We will ask athletic trainers, physicians, and others who were witnesses to the injury event or provided care after the event about the injuries, the medical care provided, and relevant prior medical history. We may request your medical information in records at hospitals, clinics or doctor’s offices where they have received care. Based on what we know at this time, the places we will seek access to your records include the office of your personal physician, physicians and nurses who cared for you during your hospital stay, hospital medical records, and information from your rehabilitation facility and staff.

2. If you sign this form, this is the health information that the persons or groups listed in #1 may give to the researchers associated with the National Center for Catastrophic Sports Injury Research:

The information we require for this research includes: injury diagnosis, treatment such as surgery and non-operative care, prior medical conditions related to the current injury, the outcome of the injury and any additional medical information that relates to the athlete’s participation in this research. The researchers would also like to obtain radiologic images including x-rays and MRIs, radiology reports and laboratory test results.

3. The HIPAA protections that apply to medical records and medical information will not apply to medical information and records when they become part of research study records. Medical information in the research study records will be shared with and used by collaborating researchers who are key members of the research team for this project and will keep this information confidential. Your records in the research study may also be shared with certain employees of the university or government agencies (like the FDA) if needed to oversee the research study. HIPAA rules do not usually apply to those people or groups. If any of these people or groups reviews your research record, they may also need to review portions of your original medical record relevant to the situation. The informed consent document describes how the research staff will protect all of the personal and medical information that is used in this research. If you have any questions about how they use personal health information or how they will protect the confidentiality of personal health information used in this research study, please contact the project director, Dr. Kristen Kucera. Her contact information is located on the first page of this form.

4. If you agree to be a part of this research study, you must sign this HIPAA authorization form to allow the persons or groups listed in #1 on this form to give the information about the athlete specified in item #2. If you do not want to sign this HIPAA authorization form, you cannot be a part of this research study. However, not signing the authorization form will not change any right to treatment, payment, enrollment or eligibility for medical services outside of this research study.

5. This HIPAA authorization will not stop unless you stop or cancel it in writing.

6. You have the right to stop or cancel this HIPAA authorization at any time. You must do that in writing by sending a note directly to principal investigator at the mailing address listed at the top of this form. Stopping this HIPAA authorization will not stop information sharing that has already happened.

7. This research is funded by the National Collegiate Athletic Association (NCAA), National Federation of State High School Associations (NFHS), American Football Coaches Association (AFCA), National Athletic Trainers' Association (NATA), National Operating Committee on Standards for Athletic Equipment (NOCSAE), and American Medical Society for Sports Medicine (AMSSM). This means that the research team is being paid by the sponsors for doing the study. In addition, a family member of Johna Register-Mihalik, a co-investigator on this study, has received money from NOCSAE for work that is not part of this study. These activities may include consulting, service on advisory boards, giving speeches, or writing reports.

8. You will be given a copy of this signed HIPAA authorization.

I have read the information provided above. I am giving permission for my personal health information to be used in research as described above.

HIPAA Authorization for Use and Disclosure of Health Information for Research Purposes

Next-of-Kin Authorization

IRB Project #: 05-0018

Form: C4

Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

Principal Investigator: Kristen Kucera, MSPH, PhD, ATC
UNC-Chapel Hill Department: Exercise and Sport Science
Mailing Address: 209 Fetzer Hall, CB#8700, Chapel Hill, NC 27599
Telephone: 919-843-8357
Email: kkucera@email.unc.edu
Co-Investigators: Robert C. Cantu, MD; Douglas J. Casa, PhD, ATC; Jonathan Drezner, MD; Johna Register-Mihalik, PhD, ATC

1. If you sign this HIPAA authorization form, you are giving your permission for the following persons or groups to give the researchers relevant information about the athlete’s catastrophic sports injury.

We will ask athletic trainers, physicians, and others who were witnesses to the injury event or provided care after the event about the injuries, the medical care provided, and relevant prior medical history. We may request the athlete’s medical information in records at hospitals, clinics or doctor’s offices where they have received care. Based on what we know at this time, the places we will seek access to the athlete’s records include the office of their personal physician, physicians and nurses who cared for them during their hospital stay, hospital medical records, and information from their rehabilitation facility and staff.

3. The HIPAA protections that apply to medical records and medical information will not apply to medical information and records when they become part of research study records. Medical information in the research study records will be shared with and used by collaborating researchers who are key members of the research team for this project and will keep this information confidential. The athlete’s records in the research study may also be shared with certain employees of the university or government agencies (like the FDA) if needed to oversee the research study. HIPAA rules do not usually apply to those people or groups. If any of these people or groups reviews the research record, they may also need to review portions of the athlete’s original medical record relevant to the situation. The informed consent document describes how the research staff will protect all of the personal and medical information that is used in this research. If you have any questions about how they use personal health information or how they will protect the confidentiality of personal health information used in this research study, please contact the project director, Dr. Kristen Kucera. Her contact information is located on the first page of this form.

4. If you agree to allow the athlete to be a part of this research study, you must sign this HIPAA authorization form to allow the persons or groups listed in #1on this form to give the information about the athlete specified in item #2. If you do not want to sign this HIPAA authorization form, the athlete cannot be a part of this research study. However, not signing the authorization form will not change any right to treatment, payment, enrollment or eligibility for medical services outside of this research study.

5. This HIPAA authorization will not stop unless you stop or cancel it in writing.

8. You will be given a copy of this signed HIPAA authorization.

I have read the information provided above. I am giving permission for the participant's health information to be used in research as described above.

HIPAA Authorization for Use and Disclosure of Health Information for Research Purposes

Parental Authorization for Minor Child

IRB Project #: 05-0018

Form: C1-C2

Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

Principal Investigator: Kristen Kucera, MSPH, PhD, ATC
UNC-Chapel Hill Department: Exercise and Sport Science
Mailing Address: 209 Fetzer Hall, CB#8700, Chapel Hill, NC 27599
Telephone: 919-843-8357
Email: kkucera@email.unc.edu
Co-Investigators: Robert C. Cantu, MD; Douglas J. Casa, PhD, ATC; Jonathan Drezner, MD; Johna Register-Mihalik, PhD, ATC

1. If you sign this HIPAA authorization form, you are giving your permission for the following persons or groups to give the researchers relevant information about your child’s catastrophic sports injury.

We will ask athletic trainers, physicians, and others who were witnesses to the injury event or provided care after the event about the injuries, the medical care provided, and relevant prior medical history. We may request the child’s medical information in records at hospitals, clinics or doctor’s offices where they have received care. Based on what we know at this time, the places we will seek access to your child’s records include the office of their personal physician, physicians and nurses who cared for your child during their hospital stay, hospital medical records, and information from their rehabilitation facility and staff.

3. The HIPAA protections that apply to medical records and medical information will not apply to medical information and records when they become part of research study records. Medical information in the research study records will be shared with and used by collaborating researchers who are key members of the research team for this project and will keep this information confidential. Your child’s records in the research study may also be shared with certain employees of the university or government agencies (like the FDA) if needed to oversee the research study. HIPAA rules do not usually apply to those people or groups. If any of these people or groups reviews the research record, they may also need to review portions of the athlete’s original medical record relevant to the situation. The informed consent document describes how the research staff will protect all of the personal and medical information that is used in this research. If you have any questions about how they use personal health information or how they will protect the confidentiality of personal health information used in this research study, please contact the project director, Dr. Kristen Kucera. Her contact information is located on the first page of this form.

4. If you agree to allow your child to be a part of this research study, you must sign this HIPAA authorization form to allow the persons or groups listed in #1on this form to give the information about the athlete specified in item #2. If you do not want to sign this HIPAA authorization form, your child cannot be a part of this research study. However, not signing the authorization form will not change any right to treatment, payment, enrollment or eligibility for medical services outside of this research study.

5. This HIPAA authorization will not stop unless you stop or cancel it in writing.

8. You will be given a copy of this signed HIPAA authorization.

I have read the information provided above. I am giving permission for my child's health information to be used in research as described above.

High School Assent to Participate in Research

IRB Study #: 05-0018

Form: C1-C2

Form Version Date: March 24, 2023

Title of Project: National Center for Catastrophic Sport Injury Research

Principal Investigator: Kristen Kucera, MSPH, PhD, ATC
UNC-Chapel Hill Department: Exercise and Sport Science
Telephone: 919-843-8357
Email: kkucera@email.unc.edu
Co-Investigators: Robert C. Cantu, MD; Douglas J. Casa, PhD, ATC; Jonathan Drezner, MD; Johna Register-Mihalik, PhD, ATC

What are some general things you should know about research studies?

You are being asked to participate in a research study. Research studies are designed to obtain new knowledge and this new information may help people in the future. They may or may not benefit you, and there may also be risks.

It is important for you to know that your parent, or guardian, needs to give permission for you to be in this study, but your participation in this study is voluntary. You may refuse to give consent, or you may withdraw your consent for any reason and at any time.

A copy of this assent form is enclosed for you to keep for your records. You should ask the researchers named above, or staff members who may assist them, any questions you have about this study at any time.

What is the purpose of this study?

How many people will take part in this study?

Approximately 150 athletes sustain a catastrophic sports injury each year. We are inviting athletes, family members, school and team officials and medical providers to provide information about the nature of the injuries and the circumstances surrounding the injury event.

What will happen if you take part in this study?

If you agree to participate, we will:

1) Ask you and your parent to participate in a 30-45 minute telephone interview consisting of questions about your age, height, weight, playing experience, previous injury experience, the circumstances of the injury event, the type of injuries, and subsequent medical treatment provided. Participation in the study is voluntary so if there is a question or questions that you do not want to answer, that is not a problem—just tell the interviewer to go on to the next question.

2) We will also ask your school staff members (athletic trainer, athletic director, coach, and/or other school staff) to participate in a similar interview.

3) For certain injuries we may also ask to interview your personal physician and the medical personnel who treated your injuries. We may request radiological images (x-rays, MRIs, CT scans) and/or other medical information such as medical records about your injury or information regarding treatment provided.

5) We may also contact you again if more information is needed, after first contacting your parents.

What are the possible risks or discomforts involved from being in this study?

Although, extremely rare, there are some potential risks involved with this study. There is the possibility that you may experience emotional distress when asked questions about the injury. Any problems or concerns should be reported to the researchers, who have been trained to provide assistance to aid in management of emotional distress.

How will your privacy be protected?

Will you receive anything for being in this study?

You will not receive any compensation for taking part in this study.

Will it cost you anything to be in this study?

There will be no costs to you for participating in this study.

What if you have questions about this study?

What if you have questions about your rights as a research participant?

I have read the information provided above. I have asked all the questions I have at this time. I voluntarily agree to participate in this research project.

ReCAPTCHA

Please Confirm You Are Not A Machine

Cancel