Jerome High School Concussion Report
Coaches: Please use this form to report any concussions, or suspected concussions, that occur during athletic practices or competitions, or that occur to your athletes during the season outside of your activity. You should also send a text to both of our trainers, or call them, so they are aware. Lon Egbert: 208.316.3090 Carla Southwick: 208.589.5027. Once you learn of a possible concussion, you should not allow the athlete to practice at all until you receive written clearance from a doctor or clearance from Lon or Carla. Once the athlete is cleared, safe return to play protocol must be followed per Idaho law. (See bottom of form for details.)
Coach's Name
Your answer
Student's First Name
Your answer
Student's Last Name
Your answer
Date of Injury
Date Parents Were Notified (Or Date Coaches Were Notified in the case of a concussion that occurred outside of the school activity.)
How were parents notified?
Do you understand that the student is not allowed to return to practice until WRITTEN clearance is provided to you by a certified professional, and that once written clearance is given, safe return to play protocol must be followed?
Please briefly explain how the injury occurred as you understand it.
Your answer
Thank you for your help! Please review the safe return to play protocol below.
HEADS UP 4 Step Process


1. Remove the athlete from play.

2. Ensure that the athlete is evaluated by a health care professional experienced in evaluating for concussion. Do not try to judge the seriousness of the injury yourself.

3. Inform the athlete’s parents or guardians about the possible concussion and refer them to the fact sheet for parents that is available on our web site on the "Coaches' Office" page.

4. Keep the athlete out of play the day of the injury. An athlete should only return to play with permission from a health care professional who is experienced in evaluating for concussion.


1. Complete physical, cognitive, emotional, and social rest is advised while the student-athlete is experiencing symptoms and signs of a sports-related concussion or other head injury. (Minimize mental exertion, limiting overstimulation, multi-tasking, etc.). Refrain from video games and texting and limit time spent working on a computer.

2. After the athlete is asymptomatic at rest and after a physician or other health care provider gives written medical clearance specially trained in the evaluation and management of concussions, the student-athlete may begin
a graduated individualized return-to-play protocol. The following steps should be followed:

• Completion of a full day of normal cognitive activities (school day, studying for tests, watching practice, interacting with peers) without reemergence of any signs or symptoms. If no return of symptoms, next day advance to -

• Light aerobic exercise, which includes walking, swimming, or stationary cycling, keeping the intensity < 70% maximum percentage heart rate: no resistance training. The objective of this step is increased heart rate. If no return of symptoms, next day advance to -

• Sport-specific exercise including skating, and/or running; no head impact activities. The objective of this step is to add
movement and continue to increase heart rate. If no return of symptoms, next day advance to -

• Non-contact training drills (e.g., passing drills). The student-athlete may initiate progressive resistance training. If no
return of symptoms, next day advance to -

• Following medical clearance (consultation between school health care personnel, i.e., Certified Athletic Trainer,
School/Team Physician, School Nurse and student-athlete’s physician), participation in normal training activities. The
objective of this step is to restore confidence and to assess functional skills by the coaching staff. If no return of
symptoms, next day advance to –

• Return to play involving normal exertion or game activity.

3. If the student athlete exhibits a re-emergence of any concussion signs or symptoms once they return to physical
activity, he/she will be removed from further exertional activities and returned to the physician or health care provider who provided written clearance for re-evaluation.

4. If concussion symptoms reoccur during the graduated return-to-play protocol, the student-athlete will return to
the previous level of activity that caused no symptoms.


Here is the link to the required Idaho Concussion Course for coaches and officials:

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