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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  jfetter@adrian.edu  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: