Concussion Report Form

CONCUSSION INCIDENT REPORT FORM

Injured Person

Name of Person Injured

Injury Date

Date of Injury

Injury Location

Where did the injury occur?

Time of Injury

What time did the injury occur

Nature of Injury

How did the injury occur?

Date Injury Reported

Date injury was reported

Concussion Symptoms

Describe if any concussion symptoms exhibited?

Event Narrative

Describe details relating to the injury

Medical Attention

Check box if medical attention was sought

If Yes

When, where, who

EG Softball League

Check box if the Elk Grove Girls Softball League Notified?

Protocol Forms

Check box if the injured given the USA Softball Protocol Forms?

Name of Reporter

Name of Reporting Party (First & Last)

Signature

Reporting Party's Signature

Required Fields