WVSSAC Concussion Report

    PART 1

    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

    BaseballBasketballCross CountryFootballSoccerSoftballTennisCheerWrestlingVolleyballTrackGolfSwimming

    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')

    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

    • Light aerobic exercise (less than 70% of maximum heart rate)

    • Sport specific exercise (drills specific to athlete's sport)

    • Non-contact training drills (more intense sport drills with no contact from other players)

    • Full participation practice (following written medical clearance)

    • Return to play (normal game play)

    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.