Your Email Address (Used for saving the report.)
Person Completing this report
Today's Date (must be submitted within 7 days)
Is this the initial concussion report?
Is this an updated report?
Please indicate the sport of this athlete
Please indicate the gender of the athlete
Please indicate the grade of the athlete
Date incident occurred
Activity when incident occurred
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 EMSReferral to parents to seek follow up evaluationReferral to team physician/Certified Athletic TrainerOther (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 'Send')
Please check that each progression has been completed with appropriate date
Days between concussion occurring and cleared to return to play
Who cleared the athlete to return
PhysicianPhysician Asst.Athletic Trainer (LAT, ATC)Licensed Physical TherapistNurse PractitionerChiropractor
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.)
Use the Send option when your report is complete. This option does not allow editing.
The "Save" option saves your information for future edits; you will receive an email with an access code so that you may add additional and updated information related to this athlete.