State High School Sports Safety Policies

Preparing for an emergency should be the top priority for schools to ensure the safety of their athletes. Through the implementation of required policies and procedures, schools can be well prepared in the unfortunate event of a catastrophic injury.

At the Korey Stringer Institute, we have established a series of policies developed from best practice documents related to the top causes of sudden death in high school athletes. These polices are relevant to the best practices developed for the top causes of sudden death in sport. Based off the “Inter-Association Task Force Document Preventing Sudden Death in Secondary School Athletics” document, the policies outlined on this website were evaluated directly from publicly available resources such as state high school associations and legislative websites.

Ranking of states regarding the implementation of evidence-based best practices for preventing and managing the leading causes of sudden death in secondary school athletics. State-Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within Secondary School Athletics, the study which details the results, is publish in The Orthopedic Journal of Sports MedicineA full recording of the press conference announcing the results is available.

2018 High School Sports Safety Policy Rankings



           Score (%) 

1 New Jersey 79.03
2 North Carolina 78.75
3 Massachusetts 71.4
4 Kentucky 71.13
5 Missouri 62.0
6 South Dakota 60.58
7 Washington 60.00
8 Wisconsin 59.13
8 Hawaii 59.13
10 Georgia 56.98
11 Arkansas 56.83
12 New York 55.75
13 Mississippi 55.25
14 West Virginia 54.33
15 Oregon 53.59
16 Virginia 53.40
17 Illinois 53.38
18 Tennessee 52.73
19 Arizona 52.00
20 Texas 50.80
21 District of Columbia 50.55
22 Utah 50.00
23 Pennsylvania 49.00
24 Florida 48.25
25 New Mexico 48.08
26 Nebraska 47.75
27 Alaska 47.40
28 Alabama 47.20
29 Maine 47.10
30 Nevada 47.00
31 Rhode Island 46.73
32 Vermont 46.38
33 Kansas 46.35
34 Indiana 46.00
35 Delaware 45.73
36 South Carolina 44.18
37 Ohio 43.93
38 Idaho 43.00
39 Maryland 42.63
40 Louisiana 41.00
41 Connecticut 40.80
42 Oklahoma 40.50
43 Michigan 39.73
44 Minnesota 38.35
45 North Dakota 38.00
46 Iowa 37.00
47 Wyoming 37.00
48 New Hampshire 36.00
49 Montana 33.25
50 California 26.00
51 Colorado 23.00

updated 7.19.18

Frequently Asked Questions

What was the purpose of this study?

The purpose of this study is to provide a graded assessment of the implementation of health and safety policies pertaining to the leading causes of sudden death and catastrophic injury in sport at the state level for secondary school athletics within the United States and District of Columbia.


What are the leading causes of death for secondary school athletes?

The leading causes of death among secondary school athletes are: sudden cardiac arrest, traumatic head injuries, exertional heat stroke, and exertional sickling.


What is exertional sickling?

Exertional sickling is a potentially fatal medical condition occurring in athletes carrying the sickle cell trait. It occurs when some of the red blood cells change into a “sickle” shape and cause a buildup of red blood cells in small blood vessels. This leads to decreased blood flow, a potential breakdown of muscle tissue, and eventually cell death, known as fulminant rhabdomyolysis.


How was each state assessed and scored?

A rubric was created in which each state was assessed based on five equally weighted sections pertaining to sudden cardiac arrest, traumatic head injuries, exertional heat stroke, appropriate medical coverage, and emergency preparedness. Current evidence-based best practices from the Interassociation Task Force for Preventing Sudden Death in Secondary School Athletics published in the Journal of Athletic Training in 2013 were used to form the content of the grading rubric.


Researchers gathered health and safety policies surrounding the leading causes of sudden death and catastrophic injury in sport from each state’s public high school athletic association, enacted legislation, and Department of Education that were in place for the 2017-2017 academic year. States received points on the rubric if associated policies were required or mandated to be followed by the state high school athletics association member schools in that respective state. States did not receive points on the rubric if polices were only recommended or encouraged. Each state received an aggregate score based on how many safety policies they had in place and how comprehensive they were. The best score was 100. Final scores were converted into percentages for each state, which were then ranked from 1 to 51 based on their percentage score.


What was the original outcome of the study in August, 2017?

North Carolina has the most comprehensive health and safety polices in place for secondary school athletics, with a score of 78.75%. Colorado has the fewest, with a score of 23%. The median state score was 47.1%. States scoring in the top 10% were North Carolina, Kentucky, Massachusetts, New Jersey, and South Dakota. States scoring in the bottom 10% were Minnesota, Montana, Iowa, California, and Colorado. A complete list of the rankings can be found above.


Have the individual states been made aware of the study results?

States were made aware of their individual score following the grading of their respective state. Individual state results were sent to each state’s high school athletics association executive director as well as the attendees of the 2017 Collaborative Solutions for Safety in Sports Meeting held in Kansas City, MO. This also allowed the state representatives the opportunity to review the rubric and provide the researchers any feedback if discrepancies were identified.


How many secondary school athletes are injured each year?

More than 7.8 million secondary school athletes participate in a wide variety of sanctioned sports annually. From 1982 to 2015, there have been 735 fatalities (185 from direct causes, 550 from indirect causes). During that time, there have also been 626 catastrophic injuries (613 from direct causes, 13 from indirect causes). Direct causes are attributed to trauma (e.g. athlete-to-athlete or athlete-to-object contact). Indirect causes are exertion based (e.g. exertional heat stroke, sudden cardiac arrest, asthma).


Can you tell me more about the evidence-based practices used in this study?

The safety measures used as the basis for this study come from evidence-based best practices that have been endorsed by some of the leading medical organizations in the United States, including: the American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine The practices have also been endorsed by the: Canadian Athletic Therapists Association, Gatorade Sports Science Institute, Korey Stringer Institute, Matthew A. Gfeller Sport-Related Traumatic Brain Injury Research Center, National Athletic Trainers’ Association, and the National Center for Catastrophic Sport Injury Research. Other endorsements include: the National Council on Strength & Fitness, National Federation of State High School Associations, National Interscholastic Athletic Administrators Association, and the National Strength and Conditioning Association. More information about these recommendations can be found in a 2013 report titled: “The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations.”