sickle cell verification form - adrian collegeadrian.edu/uploads/files/sickle_cell.pdf ·...
TRANSCRIPT
Adrian College Athletic Training Sickle Cell Trait Status Verification Form
The NCAA is mandating that its member institutions verify Sickle Cell Trait status of every student athlete. Sickle cell trait is not a disease, but rather a genetic predisposition to a sickle shaping of the oxygen-‐carrying red blood cells during intense exercise and/or extreme heat. Although there are no requirements that limit participation in sports by student athletes who have the sickle cell trait, the NCAA recommends Athletic Departments identify each student athlete’s status to better educate and identify high risk student athletes. All student athletes at Adrian College are required to provide documentation demonstrating the presence or absence of sickle cell trait. Typically, this test is performed on all newborns in the United States; however, those records may be difficult to access. Please have your healthcare provider complete this form by doing a sickle cell trait test, documenting results from a previous test, or discussing and signing the waiver option. You will be unable to compete as an athlete until this form and all other medical forms are completed and turned into the athletic training staff. Please contact Jamie Fetter, MS, AT/L, Head Athletic Trainer at [email protected] for further information or questions. Thank you for your attention to this important matter. To be completed by a healthcare provider (MD, DO, NP, PA): Student Athlete Name:_________________________________________________ Date of Birth:______________
Contraindications to Activity: ____________________________________________________________
Healthcare Provider Name: ________________________________________________(MD, DO, NP, PA)
Address: _________________________________________ City, State, Zip: _______________________
Telephone Number for Consultations: ______________________________________________________
Healthcare Provider Signature: ________________________________________ Date: ______________
As a part of the NCAA mandate, the student athlete has the option to sign a waiver to decline confirmation of his/her sickle cell trait status. By choosing this option, the student athlete understands that neglecting to identify his/her sickle cell trait status may lead to exertional sickling, cramping, heat exhaustion or sudden death.
Student Athlete Name: ___________________________________________________ Date: ______________
Sickle Cell Trait Positive □ Sickle Cell Trait Negative □ Date of Sickle Cell Testing: