1 WVSSAC CONCUSSION REPORT « WVSSAC

WVSSAC CONCUSSION REPORT

PART 1

Your Email Address (Used for saving the report.)

School

Person Completing this report

Position

Date (must be submitted within 7 days)

Is this the initial concussion report?
Yes No 

Is this an updated report?
Yes No 

Please indicate the sport of this athlete
Baseball Basketball Cross Country Football Soccer Softball Tennis Cheer Wrestling Volleyball Track Golf Swimming 

Date incident occurred

Activity when incident occurred
Practice Scrimmage Game 

Who observed the incident involving this athlete? (By title/role - no name; athletic trainer, EMT, coach, etc)

Initial steps included
 Transported by EMS Referral to parents to seek follow up evaluation Referral to team physician/Certified Athletic Trainer Other

Was the athlete diagnosed with a concussion?
Yes (If Yes, complete PART 2 before Submitting) No (If No, go to bottom of form and hit 'Send') 

PART 2 (This must be within 30 days of the injury)

Please check that each progression has been completed with appropriate date

  •  No activity with complete physical and cognitive test
    Date:
  •  Light aerobic exercise (less than 70% of maximum heart rate)
    Date:
  •  Sport specific exercise (drills specific to athlete's sport)
    Date:
  •  Non-contact training drills (more intense sport drills with no contact from other players)
    Date:
  •  Full participation practice (following written medical clearance)
    Date:
  •  Return to play (normal game play)
    Date:

Days between concussion occurring and cleared to return to play

Who cleared the athlete to return
Physician Physician Asst. Athletic Trainer (ATC/R) Licensed Physical Therapist Nurse Practitioner Chiropractor 

Keep the "Approval for Return to Play" document at the school.
(if the athlete is not cleared to return in 30 days, the initial report must be submitted and then a follow up report must be submitted listing the return to play date.)