Your Email Address (Used for saving the report.)
Person Completing this report
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
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')
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
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.)