Table 8. . Robust quotes used to make themes.

Theme	Quote
Theme 1	P1: “What we're using (for on-field assessments) is a written document that has been provided by the State of New Jersey. It is a one-page sheet that describes the signs and symptoms of a concussion and the appropriate actions that should be taken should the student athlete exhibit any of those signs or symptoms. Once those signs and symptoms are presented to a school official, the next step is to run it through the athletic trainer, who describes the policy to the parents and (informs the parents) that the child needs to be evaluated by a physician trained in concussion management.” P9: “Unfortunately, the SCAT is a great resource, but I feel like most kids even with a concussion can do very well on the SCAT form.” P2: “I will use an on-field evaluation such as the SCAT … Most athletes know how to fake (not having a concussion) till they make it, (but) you cannot fake your cognitive or your motor (function), so it is important that it is not just, ‘Do you have blurry vision? No? Okay, you are ready, you can go back.’” P10: “From an assessment standpoint, you really have to use a multifaceted approach. You cannot just rely on if they have a headache or not. There are just so many other things that can be affected. So, looking at the sense of balance, talking to the parents, talking to people who see (the injured athlete) on a day-to-day basis. Giving them some set time as well, if they do not have a headache five or ten min after the injury, but 24 h post-, now it is a different story. So, you definitely have to make sure that your diligence and making sure that you are, you know, you take a multifaceted approach.” P11: “By law, (students athletes exhibiting signs of concussion) need to be seen and cleared by a physician who is trained in the evaluation and management of head injury and concussion.” P6: “That is in the law: if an athlete has signs and symptoms of concussion, they need to be referred to a concussion specialist.” P1: “Our state instituted a law for the management of concussions, and our (school) policy follows the standards of that law.” P8: “We follow the state guidelines for concussion management, that (students) have to get cleared by a doctor. Then we do follow the 7 day symptom free (guideline) before they can do the return-to-play protocol.” P7: “We wait 24 h and see how they feel. If they feel fine in less than 24 h and a SCAT was totally clear or almost, like almost perfect 29 and 30, somewhere around there. As opposed to the patient who comes in the next day and says, ‘I feel worse or I am still hurt, I still have a headache.’ Then we will call the parents and say, ‘Okay, he is not going to be able to play until he sees a doctor.’ Then they will see the doctor, and they will start the protocol.” P7: “It is usually 24 h symptom-free, then return to some moderate activity. Maybe the first and second day, treadmill and then a couple of days of practice. The first day (of practice), a little less vigorous, less contact and then the second day of practice full. Then a final doctor’s clearance, with final review of their post injury impact test from the doctor.” P5: “Some students exhibit symptoms right away and we begin to facilitate a physician visit. Others we monitor overnight and into the next day to see if and how symptoms progress and then make a decision at that time.” P2: “The policy is set forth by whatever policy company creates policies for the school, based off of Zurich statement … our team doctor is the one that can amend or waive some of the policy.” P2: “We have to defer to the parent. Ultimately, it is their decision. I give the sheet that has the signs and symptoms … I try to give them the information I have myself. I give them my opinion.” P4: “(The procedure for referrals) was never specifically just spelled out. I just always remembered, even at the college level, it is between you and the doctor to kind of get (the athlete) back in play. I am sorry, I do not think I have ever heard someone specifically say a ‘multifaceted approach.’” P8: “I wish the state would be more specific with the laws and following this 7-day protocol, because it is only a guideline.” P8: “(The guidelines) say that you need to be cleared by a doctor, but they are not specific on what kind of doctor.”
Theme 2	P1: “I think we are lucky in our area that there are about ten physicians that do a really great job … between those ten physicians, it never takes more than a couple of days to get an appointment.” P5: “I am very fortunate to have a great group of physicians that work closely with our student athletes. Referral is often very quick and painless.” P6: “I absolutely love it … the concussion specialists, those guys are phenomenal … If anything happens or they evaluate somebody, they call me up right away.” P4: “I do not love it.” P4: “Parents here already have doctors that they like, or, ‘Oh, I heard so-and-so went to this doctor and he cleared (the student to return to play) in 2 days, so we are going to send our daughter there.’ So, that part I do not like, because it is kind of a free-for-all. I call the parent and let them know, ‘Hey, your daughter has a possible concussion. She needs to get evaluated by a doctor, a concussion specialist. Here is a place that I recommend. Here is the information.’ Then whether they go there or not, it is a crapshoot.” P2: “It is tough, because a lot of our athletes are just going to be going to a general practitioner or a walk-in … some of our student athletes have issues with getting to neurologists.” P3: “It depends on the doctors that (the students) go to.” P9: “Unfortunately, some of the parents and their kids like to try to get around (the referral requirement). I have had someone cleared by a foot doctor. I had someone cleared by a gynecologist.”
Theme 3	P3: “I have had doctors say, ‘Well, if they did not throw up, it is not a concussion.’ I was like, ‘that is not how it works.’” P8: “(Some doctors) won’t even recognize an injury as a concussion, because their justification is, ‘He did not lose consciousness,’ or, ‘He did not vomit.’” P8: “[Uninformed doctors will] return a kid back to play before their symptoms are resolved.” P3: “It is frustrating to know that the majority of doctors still don't know the updated information when it comes to treating concussion or knowing what a concussion is.” P8: “If the doctor is trained in concussions, I feel fairly secure and safe with that and I do not have a problem returning kids to play.” P1: “Because the law does not specifically speak to what does it means to be trained in concussion management, the family doctor could just turn around and say, ‘I read an article, so I know what I am doing.’” P1: “The most difficult challenge is convincing the parents they should go to a small subset of physicians in our area who really know what they are doing in concussion management and not just go to the family doctor.” P4: “A barrier would be just educating the parents on what RTP means. They hear RTP, and they are like, ‘Great, (the student’s) gonna quit play for 2 hours,’ whereas that is not a RTP.” P2: “A parent may come back with a clearance from imaging and think that that is okay … (but) the CAT scan’s not going to show a concussion.” P6: “The barriers are, I know the crappy doctors from the good doctors, and when a parent says, ‘I am gonna take him over here (to an unqualified doctor),’ there is nothing I can do, because I am not allowed to say, ‘We need to take him (to a qualified doctor instead).’ The parent’s choice is to take (the student) wherever their insurance covers and wherever the parent wants to drive to get a recommendation.” P8: “(A barrier has) been insurance issues. If I try to get (students) to a concussion center or a department that specializes in concussion, their insurance may not cover it.” P9: “We have some income issues in our area. So sometimes insurance is an issue … It is a little struggle getting the kids to the doctor in a timely manner, because the parents do not have insurance.”
Theme 4	P2: “Overbearing coach … wants to put (the student) right back in (play), but you need to let these things simmer a little bit to see if there is the progression of an injury.” P7: “There was a lot of pressure with coaches (saying), ‘So Johnny came out and they had their head hurt, but that is football.’” P8: “The coaches tend to pressure me. Like, ‘Oh, there is no concussion.’ They will deny the injury or the severity of the concussion, like, ‘Oh, he just got dinged,’ or ‘They are faking it.’” P1: “When I make that initial determination that this individual has enough signs and symptoms of a concussion that they need to be placed into the concussion protocol, the pushback that I get (is) from the parents, because they know that their child, without question, is going to be out of activity for what seems to them to be an eternity, that it is going to be 1, 2 and 3 weeks.” P9: “The coaches and the parents are on you to get (concussed athletes) cleared as quick as possible: ‘Why do they have to use a protocol, why is it this, why is it that?’ They always question it.” P11: “The athlete and the parents and the coach, they want to get (the students back into play) sooner rather than later.” P11: “Lack of education on all parties fronts … not understanding RTP.” P5: “I make sure our parent body understands the protocols that are in place and that there are no exceptions to these protocols.” P6: While you need to get him back and he is our top player, it is just not going to happen. We are going to follow the state law and that is it.”
Theme 5	P11: “A multifaceted tool that we now have to use, from the comprehensive exam of the SCAT 5 with the use of impact and neurocognitive testing, we have a lot of options to better help our patients.” P5: “We are extremely successful in the management of concussions, and I believe this is due to a multifaceted approach.” P5: “The main benefit I see is that our students receive the best possible care and are healed before resuming activity.” P1: “The educational piece (of a multifaceted approach) has been the biggest thing. Before we started this policy, I saw two, three, maybe four concussions a year … (Since) the 1st year we instituted the education … we have averaged between 25 and 30 concussions a year … What it is telling me is for 8 or 10 years prior to the policy, there were still (laughs), 25 kids a year getting a concussion and I was only seeing two or three or four of them.” P7: “I think it is much better than when I first was dealing with concussions, 20 years ago. It is safer for the patient. We have a specific plan in place that seems to protect the patient from anything getting worse.” P10: “I think it is satisfying because, I think, we are doing whatever we can (in using a multifaceted approach) … to improve on what we can offer and get to our athletes.”

RTP: Return-to-play; SCAT: Sport Concussion Assessment Tool.