Suspected Concussion Recording
As the Team Medic you should complete this form as soon as possible after the incident / injury
Email address *
Name of Medic *
Your answer
Name of Casualty *
Your answer
Date of Injury *
MM
/
DD
/
YYYY
Contact Telephone Number for Parent / Guardian / Player *
Your answer
Email address of Parent / Guardian / Player *
Your answer
Team *
Nature of Injury *
Method of Assessment *
Parent / Guardian / Player advised to obtain professional Medical Advice and notified that a medical note required to clear player for play / training from either Up and Running or Valiant Clinic? *
Required
Is this Suspected Concussion *
Required
Has advice on Immediate Management of Concussion or Suspected Concussion been issued to the Player / Parent / Guardian?
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