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MHSL
WVSSAC Concussion Report
Complete Part 1 and Part 2 and submit within 30 days of the incident.
Part 1
School
Name of Person Completing This Report
Position of Person Completing Report (ex. LAT/ATC, EMT, Head Coach, etc.)
Email of Person Submitting Report
Today's Date (submitted within 30 days of incident)
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
Please indicate the gender of the athlete
Male
Female
Please indicate the grade of the athlete
6
7
8
9
10
11
12
Date incident occurred
Activity when incident occurred
Practice
Scrimmage
Game
Other
If other, please specify:
Who observed the incident involving this athlete? (By title/role - no name; athletic trainer, EMT, coach, etc) - include additional description of incident as appropriate.
Initial steps included
Transported by EMS
Referral to parents to seek follow up evaluation
Referral to team physician/Certified Athletic Trainer
Other (Please Describe Below)
Other, if applicable
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 'Submit')
PART 2
Please check that each progression has been completed with appropriate date
No activity with complete physical and cognitive test
No activity with complete physical and cognitive test
Date
No activity with complete physical and cognitive test
Light aerobic exercise (less than 70% of maximum heart rate)
Date
Sport specific exercise (drills specific to athlete's sport)
Sport specific exercise (drills specific to athlete's sport)
Date
Non-contact training drills (more intense sport drills with no contact from other players)
Non-contact training drills (more intense sport drills with no contact from other players)
Date
Full participation practice (following written medical clearance)
Full participation practice (following written medical clearance)
Date
Return to play (normal game play)
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 (LAT, ATC)
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 within 30 days, the initial report must be submitted and then a follow up report must be submitted listing the return to play date.)
Submit
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